| NPI | 1114660966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MN 04325) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 305842) |
| Enumeration Date | 2022-04-19 |
| Last Update Date | 2024-03-21 |