| NPI | 1902863616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103G00000X Clinical Neuropsychologist (Licence: MA 6635) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 6635) |
| 103TR0400X Psychologist Rehabilitation (Licence: MA 6635) | |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2007-07-08 |