| NPI | 1104414515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN 4208) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 305850) |
| 101YM0800X Counselor, Mental Health (Licence: WI 11496-125) | |
| Enumeration Date | 2021-01-03 |
| Last Update Date | 2026-02-06 |