| NPI | 1871617258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QV0200X Clinic/Center VA (Licence: MA 7798) |
| Additional Taxonomies | 103G00000X Clinical Neuropsychologist (Licence: MA 7798) |
| 103TC0700X Psychologist Clinical (Licence: MA 7798) | |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2017-04-03 |