| NPI | 1619254778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 9425) |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 9425) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 9425) | |
| Enumeration Date | 2011-11-03 |
| Last Update Date | 2012-09-05 |