| NPI | 1679596126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NH 330) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 3115) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2007-07-08 |