| NPI | 1912060583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: KY 25478) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2023-03-07 |