| NPI | 1104346402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301019304) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301017108) |
| 101YP2500X Counselor Professional (Licence: IL 178.008499) | |
| 103T00000X Psychologist (Licence: MI 6301017108) | |
| Enumeration Date | 2017-06-27 |
| Last Update Date | 2023-12-26 |