| NPI | 1568062461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP7006) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 304713) |
| 101YM0800X Counselor, Mental Health (Licence: MN 2349) | |
| Enumeration Date | 2020-10-29 |
| Last Update Date | 2024-01-31 |