| NPI | 1508453556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95036358) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95178155) |
| Enumeration Date | 2020-12-23 |
| Last Update Date | 2025-12-16 |