| NPI | 1720477573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MI 6401001620) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301008639) |
| Enumeration Date | 2015-01-16 |
| Last Update Date | 2015-04-07 |