| NPI | 1376015719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MN CC02773) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 304937) |
| Enumeration Date | 2018-12-26 |
| Last Update Date | 2022-01-12 |