| NPI | 1639182256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QV0200X Clinic/Center, VA (Licence: MA 6647) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 6647) |
| 103TC0700X Psychologist, Clinical (Licence: NY 011533) | |
| 261QV0200X Clinic/Center, VA (Licence: NY 011533) | |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2020-10-02 |