| NPI | 1750485744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP1640) |
| Additional Taxonomies | 103T00000X Psychologist |
| 103TC0700X Psychologist, Clinical (Licence: MN LP1640) | |
| Enumeration Date | 2006-09-11 |
| Last Update Date | 2023-06-01 |