| NPI | 1295883734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN 5493) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MN 5493) |
| 103TF0000X Psychologist Family (Licence: MN 5493) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MN 5493) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN 5493) | |
| 103TH0004X Psychologist Health (Licence: MN 5493) | |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2012-06-04 |