| NPI | 1972607562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP5043) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: WI 3386-125) |
| 101YP2500X Counselor, Professional (Licence: IA 00871) | |
| 101YP2500X Counselor, Professional (Licence: MN 00018) | |
| 101YP2500X Counselor, Professional (Licence: IL 180-003674) | |
| Enumeration Date | 2006-09-12 |
| Last Update Date | 2018-03-17 |