| NPI | 1932587078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 10670) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 10670) |
| Enumeration Date | 2015-05-08 |
| Last Update Date | 2022-05-11 |