| NPI | 1730243031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 1020) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MA 1020) |
| 103TA0700X Psychologist Adult Development & Aging (Licence: MA 1020) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: MA 1020) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 1020) | |
| 103TF0000X Psychologist Family (Licence: MA 1020) | |
| 103T00000X Psychologist (Licence: MA 1020) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2015-11-20 |