| NPI | 1538410246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP 1275) |
| Additional Taxonomies | 283Q00000X Psychiatric Hospital (Licence: MN LP 1275) |
| Enumeration Date | 2012-09-21 |
| Last Update Date | 2012-09-21 |