| NPI | 1407476336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5017612) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA 201805) |
| Enumeration Date | 2020-04-21 |
| Last Update Date | 2025-06-03 |