| NPI | 1104992940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP2262) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN 550) |
| Enumeration Date | 2006-11-24 |
| Last Update Date | 2007-07-08 |