| NPI | 1881924538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 3211) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MA 3211) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 3211) | |
| Enumeration Date | 2009-12-31 |
| Last Update Date | 2009-12-31 |