| NPI | 1801506704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MN 4158) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 303086) |
| Enumeration Date | 2022-12-01 |
| Last Update Date | 2024-03-06 |