| NPI | 1184005613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP6449) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NE 10061) |
| 101YM0800X Counselor, Mental Health (Licence: NE 4807) | |
| 101YM0800X Counselor, Mental Health (Licence: NE 539) | |
| Enumeration Date | 2015-06-10 |
| Last Update Date | 2019-09-20 |