| NPI | 1104967660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NJ 26nj000222200) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NJ 1163) |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2008-05-02 |