| NPI | 1124706635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CT 12051) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F405084-01) |
| Enumeration Date | 2023-07-06 |
| Last Update Date | 2025-03-25 |