| NPI | 1265143721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5017891) |
| Additional Taxonomies | 251S00000X |
| 261QC1500X Clinic/Center, Community Health | |
| Enumeration Date | 2022-12-06 |
| Last Update Date | 2024-07-21 |