| NPI | 1629087564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 7970) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: RI PS00803) |
| Enumeration Date | 2006-08-07 |
| Last Update Date | 2007-07-09 |