| NPI | 1699117317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301016222) |
| Additional Taxonomies | 247200000X Technician, Other |
| 101YA0400X Counselor Addiction (Substance Use Disorder) | |
| Enumeration Date | 2013-07-23 |
| Last Update Date | 2022-07-21 |