| NPI | 1972654325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MS 55 308) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling |
| 103TC2200X Psychologist Clinical Child & Adolescent | |
| Enumeration Date | 2007-01-14 |
| Last Update Date | 2007-07-08 |