| NPI | 1518599323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MN 2269) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 304316) |
| Enumeration Date | 2020-02-10 |
| Last Update Date | 2020-02-10 |