| NPI | 1659768513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TH0100X Psychologist, Health Service (Licence: MA 10444) |
| Additional Taxonomies | 103TH0100X Psychologist, Health Service (Licence: RI 02021) |
| 103TH0100X Psychologist, Health Service (Licence: CA 28469) | |
| 103TH0100X Psychologist, Health Service (Licence: NY 024896) | |
| Enumeration Date | 2015-04-17 |
| Last Update Date | 2022-05-18 |