| NPI | 1174101422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0024191627) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: VA 0001307548) |
| Enumeration Date | 2021-03-30 |
| Last Update Date | 2025-03-25 |