| NPI | 1295738029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP4505) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MO 2001032011) |
| 101Y00000X Counselor (Licence: 88344) | |
| 101YM0800X Counselor, Mental Health (Licence: MN LP4505) | |
| 103T00000X Psychologist (Licence: MN LP4505) | |
| 103TC1900X Psychologist, Counseling (Licence: MN LP4505) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: MN LP4505) | |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2020-07-02 |