| NPI | 1578085601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6362009284) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2017-07-11 |
| Last Update Date | 2021-06-03 |