| NPI | 1710258637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.015542) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IL 041398098) |
| Enumeration Date | 2012-01-24 |
| Last Update Date | 2019-03-11 |