| NPI | 1619060001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 2716) |
| Additional Taxonomies | 103TH0100X Psychologist, Health Service (Licence: MA 2716) |
| Enumeration Date | 2006-09-30 |
| Last Update Date | 2011-08-17 |