Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 300543 | MN |
NPI | 1144495391 |
---|---|
Provider Name | Mr. David Edward Schlack |
First Address | Litchfield, MN 55355 |
Second Address | Litchfield, MN 55355 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2008 |
Last Update Date | 29/04/2008 |