| NPI | 1669462669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CT 722) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 2316) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2007-07-08 |