| NPI | 1912014853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QV0200X Clinic/Center, VA (Licence: MA 2385) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 2385) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2015-05-20 |