| NPI | 1174065726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11039003) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2016-11-14 |
| Last Update Date | 2025-09-01 |