| NPI | 1356101729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11041075) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: FL IMT4281) |
| 163W00000X Registered Nurse (Licence: FL 9194886) | |
| Enumeration Date | 2024-03-21 |
| Last Update Date | 2025-09-13 |