| NPI | 1023244548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 4063341) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: KY 280816) |
| Enumeration Date | 2009-06-10 |
| Last Update Date | 2026-09-03 |