| NPI | 1700175767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NY F406110-01) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: NY F406110-01) |
| Enumeration Date | 2011-03-30 |
| Last Update Date | 2025-01-09 |