| NPI | 1245458751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP7189) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103T00000X Psychologist (Licence: AZ AZ004526) | |
| Enumeration Date | 2007-04-22 |
| Last Update Date | 2026-02-20 |