| NPI | 1821018078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MI 6401008871) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 049702538) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2019-01-14 |