| NPI | 1265035257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: UT 6210942-4405) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: UT 6210942-3102) |
| Enumeration Date | 2020-11-20 |
| Last Update Date | 2021-09-22 |