| NPI | 1659636496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 10427) |
| Additional Taxonomies | 101Y00000X Counselor |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: MA 10427) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MA 10427) | |
| Enumeration Date | 2012-07-09 |
| Last Update Date | 2016-09-09 |