| NPI | 1659640415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1113490) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: NY 308726-1) |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2023-10-25 |