| NPI | 1679690960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling (Licence: MN LP4671) |
| Additional Taxonomies | 103TF0200X Psychologist, Forensic (Licence: MN LP 4671) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2007-07-08 |