| NPI | 1912367947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 11446) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 11446) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-03-03 |
| Last Update Date | 2021-09-07 |