| NPI | 1255926143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 405300000X Prevention Professional (Licence: MI 680115877) |
| Additional Taxonomies | 103TM1800X Psychologist Mental Retardation & Developmental Disabilities |
| Enumeration Date | 2021-03-03 |
| Last Update Date | 2021-03-03 |