| NPI | 1972252617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: MN 24719) |
| Additional Taxonomies | 1041C0700X Social Worker Clinical (Licence: MN 24719) |
| Enumeration Date | 2022-03-21 |
| Last Update Date | 2024-10-03 |