| NPI | 1710268503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: VA 0810003717) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: VA 0810003717) |
| 103TC0700X Psychologist Clinical (Licence: VA 0810003717) | |
| 103TF0000X Psychologist Family (Licence: VA 0810003717) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: VA 0810003717) | |
| Enumeration Date | 2011-09-07 |
| Last Update Date | 2011-09-07 |