| NPI | 1396136040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R191093) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: DC RN1019892) |
| Enumeration Date | 2015-02-16 |
| Last Update Date | 2026-06-12 |