| NPI | 1891886321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 2534) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MA 2534) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: MA 2534) | |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2007-07-08 |