| NPI | 1346433505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6301013633) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2007-08-21 |
| Last Update Date | 2009-02-12 |