| NPI | 1679624944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA 970) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NJ 1114) |
| Enumeration Date | 2007-01-15 |
| Last Update Date | 2007-07-08 |