| NPI | 1912255449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP5676) |
| Additional Taxonomies | 103TH0004X Psychologist, Health (Licence: MN LP5676) |
| 103T00000X Psychologist (Licence: MN LP5676) | |
| Enumeration Date | 2012-08-15 |
| Last Update Date | 2021-10-25 |