| NPI | 1972682847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP0709) |
| Additional Taxonomies | 103TA0700X Psychologist Adult Development & Aging (Licence: MN LP0709) |
| 103TC0700X Psychologist Clinical (Licence: MN LP0709) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP0709) | |
| 103TF0200X Psychologist Forensic (Licence: MN LP0709) | |
| 103TF0000X Psychologist Family (Licence: MN LP0709) | |
| Enumeration Date | 2006-11-03 |
| Last Update Date | 2011-11-18 |