| NPI | 1619790607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CT 15201) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: NY 829589) |
| Enumeration Date | 2024-11-06 |
| Last Update Date | 2025-08-08 |