| NPI | 1750461109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 6702) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: MA 6702) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2007-07-08 |