| NPI | 1366467052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP0111) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: MN 0190) |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2017-02-27 |