| NPI | 1649781311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN 2401) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 304774) |
| Enumeration Date | 2017-10-20 |
| Last Update Date | 2020-02-11 |