| NPI | 1891086005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP5333) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MN LP5333) |
| 103TC0700X Psychologist Clinical (Licence: MN LP5333) | |
| 103TC1900X Psychologist Counseling (Licence: MN LP5333) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP5333) | |
| 103TF0000X Psychologist Family (Licence: MN LP5333) | |
| 103TH0100X Psychologist Health Service (Licence: MN LP5333) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MN LP5333) | |
| Enumeration Date | 2011-04-21 |
| Last Update Date | 2020-04-14 |