| NPI | 1366796088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MA RN233605) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA NP233605) |
| 101YP2500X Counselor, Professional (Licence: MA 233605) | |
| Enumeration Date | 2012-11-02 |
| Last Update Date | 2017-10-23 |