| NPI | 1700213428 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 8466) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) |
| 103TB0200X Psychologist Cognitive & Behavioral | |
| 103TC2200X Psychologist Clinical Child & Adolescent | |
| Enumeration Date | 2013-09-27 |
| Last Update Date | 2013-09-27 |