| NPI | 1407460983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 256548) |
| Additional Taxonomies | 163WP0807X Registered Nurse, Psych/Mental Health, Child & Adolescent (Licence: MD R217419) |
| Enumeration Date | 2020-09-02 |
| Last Update Date | 2022-09-06 |