| NPI | 1851446629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: MA 8294) |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 8294) |
| 103TC0700X Psychologist, Clinical (Licence: MA 8294) | |
| 103TC1900X Psychologist, Counseling (Licence: MA 8294) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 8294) | |
| 103T00000X Psychologist (Licence: MA 8294) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MA 8294) | |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2007-07-08 |