| NPI | 1104155126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704318966) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MI 6401011520) |
| Enumeration Date | 2009-12-22 |
| Last Update Date | 2025-05-07 |