| NPI | 1821113598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3307) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 3307) |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MA 3307) | |
| Enumeration Date | 2007-03-20 |
| Last Update Date | 2007-07-08 |