| NPI | 1740128958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NM 54778) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA 95039208) |
| Enumeration Date | 2026-03-23 |
| Last Update Date | 2026-05-12 |