| NPI | 1760407696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 63010013057) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MI 6301013057) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301013057) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: MI 6301013057) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2025-07-10 |