| NPI | 1851775308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP6040) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP6040) |
| Enumeration Date | 2015-07-15 |
| Last Update Date | 2021-01-26 |