| NPI | 1639662166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6301000686) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: MI 6401005067) |
| Enumeration Date | 2018-06-09 |
| Last Update Date | 2018-06-09 |