| NPI | 1205271822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301015252) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MI 6301015252) |
| 103T00000X Psychologist (Licence: MI 6301015252) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: MI 6301015252) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301015252) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: MI 6301015252) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MI 6301015252) | |
| 103TS0200X Psychologist School (Licence: MI 179302) | |
| 104100000X Social Worker (Licence: MI 6801013804) | |
| 1041C0700X Social Worker Clinical (Licence: MI 6801013804) | |
| Enumeration Date | 2013-05-09 |
| Last Update Date | 2013-05-09 |