| NPI | 1003468547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MN 23792) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 303990) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2020-03-06 |