| NPI | 1487402855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: LA 202801) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: LA 12373) |
| Enumeration Date | 2024-05-09 |
| Last Update Date | 2025-02-20 |