| NPI | 1518336767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MN CC01043) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 301969) |
| 101YP2500X Counselor Professional (Licence: MN CC01043) | |
| Enumeration Date | 2015-09-17 |
| Last Update Date | 2023-09-28 |