| NPI | 1265654586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 5381725) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: ID CHIA-1235) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2026-07-24 |