| NPI | 1033460829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MI 6801095442) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2012-09-20 |
| Last Update Date | 2017-11-27 |