| NPI | 1912474354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11006595) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: FL 18-68673) |
| Enumeration Date | 2018-10-24 |
| Last Update Date | 2020-10-08 |