| NPI | 1073169678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN 2469) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: CO 0016288) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 303235) | |
| Enumeration Date | 2019-08-11 |
| Last Update Date | 2021-10-31 |