| NPI | 1760533467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3453) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NH 165) |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2019-03-19 |