| NPI | 1104394212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP6328) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: MN LP6328) |
| 103TF0200X Psychologist Forensic (Licence: MN LP6328) | |
| Enumeration Date | 2018-11-06 |
| Last Update Date | 2022-08-02 |