| NPI | 1164810610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: SC 2255) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: SC 92956) |
| Enumeration Date | 2015-01-07 |
| Last Update Date | 2024-03-03 |