| NPI | 1154964294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MN CC02154) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 304529) |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2019-10-22 |