| NPI | 1962797548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 7664) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NH 685) |
| Enumeration Date | 2011-06-13 |
| Last Update Date | 2011-06-13 |