| NPI | 1629000757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MI 6801059734) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301004044) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2017-01-12 |