| NPI | 1104545276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MI 6801121432) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2022-08-23 |
| Last Update Date | 2026-05-08 |