| NPI | 1720198500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3047) |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 3047) |
| 103TC1900X Psychologist, Counseling (Licence: MA 3047) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 3047) | |
| 103TF0200X Psychologist, Forensic (Licence: MA 3047) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2007-10-10 |