| NPI | 1750979803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11010155) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11010155) | |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2023-12-30 |