| NPI | 1619402450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 3011456) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OH 0028202) |
| Enumeration Date | 2017-05-01 |
| Last Update Date | 2022-03-24 |