| NPI | 1760740914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI L2083531) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MI L1791411) |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2012-04-25 |