| NPI | 1467547257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP0783) |
| Additional Taxonomies | 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: MN LP0783) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2019-02-06 |