| NPI | 1972574473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NY 016499) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: VT 048-0000679) |
| 103TC0700X Psychologist, Clinical (Licence: IL 071-005496) | |
| 103TF0200X Psychologist, Forensic (Licence: VT 048-0000679) | |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2014-04-24 |