| NPI | 1629593504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MN 23615) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2017-08-11 |
| Last Update Date | 2025-04-01 |