| NPI | 1063930238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 304904) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: MN 116734) |
| 183500000X Pharmacist (Licence: SD 4890) | |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2017-09-07 |