| NPI | 1699117317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301016222) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 103T00000X Psychologist (Licence: MI 6301016222) | |
| 103TC0700X Psychologist, Clinical (Licence: MI 6301019534) | |
| 247200000X Technician, Other | |
| Enumeration Date | 2013-07-23 |
| Last Update Date | 2025-05-10 |