| NPI | 1518787696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209031254) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704421713) |
| 163W00000X Registered Nurse (Licence: IL 041502075) | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: WI 1632233) | |
| Enumeration Date | 2024-10-14 |
| Last Update Date | 2025-03-25 |