| NPI | 1073610655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP 1207) |
| Additional Taxonomies | 1041C0700X Social Worker Clinical (Licence: MN LICSW 647) |
| 106H00000X Marriage & Family Therapist (Licence: MN LMFT 028) | |
| Enumeration Date | 2006-09-17 |
| Last Update Date | 2007-07-09 |