| NPI | 1598055311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP3394) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN 12495) |
| Enumeration Date | 2011-04-13 |
| Last Update Date | 2011-04-13 |