| NPI | 1306490255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F403226-01) |
| Additional Taxonomies | 163WP0807X Registered Nurse, Psych/Mental Health, Child & Adolescent (Licence: CT 10.124129) |
| Enumeration Date | 2019-07-30 |
| Last Update Date | 2026-07-09 |