| NPI | 1861154353 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL APRN11015924) | 
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: FL 11015924) | 
| Enumeration Date | 2021-10-12 | 
| Last Update Date | 2025-04-10 |