| NPI | 1821150129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MA 158438) |
| Additional Taxonomies | 283Q00000X Psychiatric Hospital |
| 261QM0850X Clinic/Center, Adult Mental Health (Licence: MA 158438) | |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2021-04-27 |