| NPI | 1538633102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11040183) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: FL RBT-18-72791) |
| Enumeration Date | 2019-01-17 |
| Last Update Date | 2025-07-11 |