| NPI | 1205462025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MN 2268) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN cc02268) |
| Enumeration Date | 2020-03-13 |
| Last Update Date | 2023-12-12 |