| NPI | 1124665039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11028630) |
| Additional Taxonomies | 103K00000X Behavior Analyst (Licence: RBT-19-1664-182413) |
| Enumeration Date | 2019-12-10 |
| Last Update Date | 2024-10-03 |