| NPI | 1164067443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CT 2020038282) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CT 139890) |
| Enumeration Date | 2019-11-11 |
| Last Update Date | 2020-09-16 |