| NPI | 1093711616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN 0488) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN LP0488) |
| Enumeration Date | 2005-06-28 |
| Last Update Date | 2026-06-18 |