| NPI | 1245281823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X (Licence: MN 44519) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MN 44519) |
| 261QM0850X Clinic/Center, Adult Mental Health (Licence: WI 48376-20) | |
| 261QM0855X Clinic/Center, Adolescent and Children Mental Health | |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2013-06-25 |