| NPI | 1467884874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6301015619) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: TN 0000159703) |
| Enumeration Date | 2013-08-08 |
| Last Update Date | 2013-08-08 |