| 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 |