| NPI | 1508234147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WV 107800) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH 18054-NP) |
| Enumeration Date | 2015-09-14 |
| Last Update Date | 2022-05-17 |