| NPI | 1114471687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301017202) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 6301015994) |
| Enumeration Date | 2016-08-12 |
| Last Update Date | 2018-10-04 |