| NPI | 1720628399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA PSY5000502) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 027485) |
| Enumeration Date | 2020-01-13 |
| Last Update Date | 2025-12-18 |