| NPI | 1588675581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP 0425) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN LICSW 00511) |
| 106H00000X Marriage & Family Therapist (Licence: MN LMFT 0087) | |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2007-07-08 |