| NPI | 1801964382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP2348) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN 8058) |
| Enumeration Date | 2006-12-01 |
| Last Update Date | 2011-12-28 |