| NPI | 1043426836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TH0004X Psychologist, Health (Licence: MN LP1890) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP1890) |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: MN LP1890) | |
| 103TA0700X Psychologist, Adult Development & Aging (Licence: MN LP1890) | |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MN LP1890) | |
| 103TC0700X Psychologist, Clinical (Licence: MN LP1890) | |
| 103TC1900X Psychologist, Counseling (Licence: MN LP1890) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MN LP1890) | |
| 103TE1100X Psychologist, Exercise & Sports (Licence: MN LP1890) | |
| 103TF0000X Psychologist, Family (Licence: MN LP1890) | |
| 103TF0200X Psychologist, Forensic (Licence: MN LP1890) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: MN LP1890) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: MN LP1890) | |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2025-09-11 |