| NPI | 1578759270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP6513) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: IA 00399) |
| Enumeration Date | 2007-09-18 |
| Last Update Date | 2020-03-13 |