| NPI | 1649273483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NY 3896-1) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: PA PS-005411L) |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2007-07-08 |