| NPI | 1023152667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 301343) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP2659) |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2007-07-08 |