| NPI | 1154903920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.022844) |
| Additional Taxonomies | 364SP0809X Clinical Nurse Specialist, Psych/Mental Health, Adult (Licence: MT 286201) |
| Enumeration Date | 2021-04-22 |
| Last Update Date | 2026-05-05 |