| NPI | 1861444382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 4661) |
| Additional Taxonomies | 103TA0700X Psychologist, Adult Development & Aging (Licence: MA 4661) |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 4661) | |
| 103TC0700X Psychologist, Clinical (Licence: MA 4661) | |
| 103TC1900X Psychologist, Counseling (Licence: MA 4661) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 4661) | |
| 103TH0100X Psychologist, Health Service (Licence: MA 4661) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MA 4661) | |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2007-07-08 |