| NPI | 1023346012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MN CC00629) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: WI 4851-125) |
| Enumeration Date | 2009-12-02 |
| Last Update Date | 2013-10-03 |