| NPI | 1174569487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TF0200X Psychologist Forensic (Licence: MN LP0626) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MN LP0626) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2011-08-10 |