| NPI | 1972968451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 4928) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 4928) |
| 103TF0200X Psychologist Forensic (Licence: MA 4928) | |
| Enumeration Date | 2015-12-28 |
| Last Update Date | 2015-12-28 |