| NPI | 1689732851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP0219) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: MN LP0219) |
| 103TR0400X Psychologist Rehabilitation (Licence: MN LP0219) | |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2007-07-08 |