| NPI | 1588739643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP1132) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN LICSW 6524) |
| 106H00000X Marriage & Family Therapist (Licence: MN LMFT 109) | |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2007-07-09 |