| NPI | 1407629975 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R236391) | 
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: DC RN1055358) | 
| Enumeration Date | 2023-11-06 | 
| Last Update Date | 2025-09-17 |