| NPI | 1902815129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MI 6401005766) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MI 6301008843) |
| Enumeration Date | 2006-08-05 |
| Last Update Date | 2015-05-08 |