| NPI | 1215457684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 9424876-4405) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: UT 9424876-3902) |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2025-10-13 |