| NPI | 1730428699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 304448) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1109) |
| Enumeration Date | 2013-02-12 |
| Last Update Date | 2016-05-18 |