| NPI | 1376206664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling (Licence: MN LP6725) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN LP6725) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-10-14 |
| Last Update Date | 2021-12-01 |