| NPI | 1740216977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 7314) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MA 7314) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2011-10-05 |