| NPI | 1205252558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MN CC1392) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 303359) |
| Enumeration Date | 2014-03-11 |
| Last Update Date | 2019-12-04 |