| NPI | 1790377331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704326909) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704326909) |
| Enumeration Date | 2021-02-05 |
| Last Update Date | 2021-09-28 |