| NPI | 1891088696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 11531) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 103TC0700X Psychologist Clinical (Licence: MA 11531) | |
| Enumeration Date | 2011-05-26 |
| Last Update Date | 2022-03-04 |