| NPI | 1356234702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID PMH06250003) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: ID 1571469) |
| Enumeration Date | 2025-06-02 |
| Last Update Date | 2025-10-06 |