| NPI | 1295066694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX AP141260) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: OH PN 19805) |
| Enumeration Date | 2010-01-25 |
| Last Update Date | 2019-05-02 |