| NPI | 1629653530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11012067) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F405584-01) |
| Enumeration Date | 2021-03-11 |
| Last Update Date | 2025-12-11 |