| NPI | 1871652263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MN 300760) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN LP1349) |
| 106H00000X Marriage & Family Therapist (Licence: MN 719) | |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2007-07-08 |