| NPI | 1770991218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: MA RN2326656) |
| Additional Taxonomies | 1041C0700X Social Worker Clinical (Licence: MA 120185) |
| 163W00000X Registered Nurse (Licence: MA RN2326656) | |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2020-02-10 |