| NPI | 1760750921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MN 28771) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: NY 24431) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 301886) | |
| Enumeration Date | 2011-12-02 |
| Last Update Date | 2021-01-13 |