| NPI | 1093087850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: SC 18139) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: LA 1112) |
| Enumeration Date | 2012-02-08 |
| Last Update Date | 2013-04-24 |