| NPI | 1578802336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MN 21849) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 302688) |
| Enumeration Date | 2013-02-13 |
| Last Update Date | 2016-04-22 |