| NPI | 1891063129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP3694) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MN LP3694) |
| Enumeration Date | 2011-12-01 |
| Last Update Date | 2024-01-18 |