| NPI | 1114762432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10028036) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: OR 10028036) |
| Enumeration Date | 2024-06-27 |
| Last Update Date | 2025-11-20 |