| NPI | 1609957505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5005524) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: NC C002032) |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2020-09-24 |