| NPI | 1720657091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN cc04742) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 305852) |
| Enumeration Date | 2021-06-22 |
| Last Update Date | 2025-03-21 |