| NPI | 1730546243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MO 2084P0800X) |
| Additional Taxonomies | 193400000X Single Specialty (Licence: MO 2084P0800X) |
| Enumeration Date | 2016-01-28 |
| Last Update Date | 2025-03-10 |