| NPI | 1366658759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MN LP 1787) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN LP 1787) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MN LP 1787) | |
| 103TF0200X Psychologist, Forensic (Licence: MN LP 1787) | |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2007-07-08 |