| NPI | 1619681988 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1026801) | 
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IA G186334) | 
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: ID 7271272) | |
| 163W00000X Registered Nurse (Licence: TX 1026801) | |
| Enumeration Date | 2023-01-10 | 
| Last Update Date | 2025-09-07 |