| NPI | 1780958512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN 3118) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 303260) |
| Enumeration Date | 2012-02-24 |
| Last Update Date | 2026-07-13 |