| NPI | 1407209620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 253J00000X Foster Care Agency |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MA RN2292446) |
| Enumeration Date | 2016-07-22 |
| Last Update Date | 2025-12-05 |