| NPI | 1649612060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: KS 45764) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: KS 191) |
| Enumeration Date | 2013-07-26 |
| Last Update Date | 2023-06-29 |