| NPI | 1982123105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MN 21621) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: CA 68262) |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2017-09-19 |