| NPI | 1134414774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MN 16420) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 301924) |
| Enumeration Date | 2011-06-11 |
| Last Update Date | 2011-06-11 |