| NPI | 1780259689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN cc04942) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2025-05-22 |