| NPI | 1003792540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH APRN.CNP.0040073) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WV 110539) |
| Enumeration Date | 2025-08-12 |
| Last Update Date | 2026-03-17 |