| NPI | 1871472639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.034683) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 296882) |
| Enumeration Date | 2025-08-27 |
| Last Update Date | 2026-04-13 |