| NPI | 1891063798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: VA 0017139232) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: VA 0015000523) |
| Enumeration Date | 2011-12-06 |
| Last Update Date | 2012-09-19 |