| NPI | 1790825503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NY 004698) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 004698) |
| 103TE1100X Psychologist, Exercise & Sports (Licence: NY 004698) | |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2022-03-01 |