| NPI | 1871039578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MD 05707) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MD 05707) |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MD 05707) | |
| Enumeration Date | 2017-01-18 |
| Last Update Date | 2017-01-18 |