| NPI | 1194870881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MN LICSW17134) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MN 17134) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2013-12-11 |