| NPI | 1821153578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3435) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 3435) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 3435) | |
| Enumeration Date | 2006-12-23 |
| Last Update Date | 2007-07-08 |