| NPI | 1912536087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 024228) |
| 103T00000X Psychologist (Licence: NY 024228) | |
| Enumeration Date | 2020-04-02 |
| Last Update Date | 2021-04-17 |