| NPI | 1457881369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6362009228) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2017-06-13 |
| Last Update Date | 2021-01-12 |