| NPI | 1972589828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN 4778) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: MN 1124) |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2012-02-10 |