| NPI | 1174035331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 303521) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) |
| 1041C0700X Social Worker, Clinical (Licence: MN 24938) | |
| Enumeration Date | 2017-10-27 |
| Last Update Date | 2023-01-26 |