| NPI | 1366538043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH 10308) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: OH C6794) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OH 976194) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2012-03-05 |