| NPI | 1679627152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA PS002625) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NJ 3492) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2007-07-08 |