| NPI | 1346320454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MI 6801062435) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MI 6401002793) |
| 103TC0700X Psychologist Clinical (Licence: MI 6301005924) | |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2011-05-12 |