| NPI | 1710643564 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R199309) | 
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD 199309) | 
| Enumeration Date | 2021-11-15 | 
| Last Update Date | 2023-07-24 |