| NPI | 1083016455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 5780) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 363AM0700X Physician Assistant, Medical | |
| 101YP2500X Counselor, Professional | |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2026-06-03 |