| NPI | 1861899932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty (Licence: AZ 255543) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NJ 26NJ00533600) |
| Enumeration Date | 2014-12-04 |
| Last Update Date | 2025-11-18 |