Individual
OBSA ALI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
6040 EARLE BROWN DR STE 310B, BROOKLYN CENTER, MN 55430-4523
(619) 808-3191
Mailing address
10717 AUSTIN ST NE APT 342, BLAINE, MN 55449-2910
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
—
—
106S00000X
Behavior Technician
—
—
225400000X
Rehabilitation Practitioner
Primary
—
—
374K00000X
Religious Nonmedical Practitioner
—
—
Other
Enumeration date
04/08/2024
Last updated
08/03/2025
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