| NPI | 1265196695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 277003331) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11015958) |
| Enumeration Date | 2021-10-22 |
| Last Update Date | 2025-05-05 |