| NPI | 1528350535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: MI S532115135684) |
| Additional Taxonomies | 171W00000X Contractor (Licence: MI S532115135684) |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2012-10-30 |