| NPI | 1861955122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MN 27219) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MN 303882) |
| Enumeration Date | 2019-04-12 |
| Last Update Date | 2021-04-16 |