| NPI | 1235320607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2019033533) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: IA 095382) |
| 101YP2500X Counselor, Professional | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IA G157335) | |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2022-10-17 |