| NPI | 1710518352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 2457011805) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| 163WP0808X Registered Nurse, Psych/Mental Health (Licence: MI 4704383923) | |
| Enumeration Date | 2020-02-02 |
| Last Update Date | 2024-03-22 |