| NPI | 1578942314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301009079) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MI 6401003835) |
| 103TS0200X Psychologist, School (Licence: MI cc-4c8860330054) | |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2015-05-27 |