| NPI | 1306868864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MI 6401004253) |
| Additional Taxonomies | 1041C0700X Social Worker Clinical (Licence: MI 6801003716) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2011-02-11 |