| NPI | 1912033648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 1315) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: MA 1315) |
| 103TA0700X Psychologist, Adult Development & Aging (Licence: MA 1315) | |
| 103TC0700X Psychologist, Clinical (Licence: MA 1315) | |
| 103TF0000X Psychologist, Family (Licence: MA 1315) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MA 1315) | |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2010-02-05 |