| NPI | 1669221768 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MN CC04387) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 305049) |
| 2084P0800X Psychiatry & Neurology Psychiatry (Licence: MN 04387) | |
| Enumeration Date | 2024-05-13 |
| Last Update Date | 2024-06-25 |