| NPI | 1710147418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP3544) |
| Additional Taxonomies | 103TP2701X Psychologist Group Psychotherapy (Licence: MN LP3544) |
| Enumeration Date | 2008-06-16 |
| Last Update Date | 2008-09-08 |