| NPI | 1801403100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP7004) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: TX 38515) |
| Enumeration Date | 2020-09-30 |
| Last Update Date | 2024-01-17 |