| NPI | 1912661364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11016129) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: FL 11016129) |
| Enumeration Date | 2021-10-22 |
| Last Update Date | 2026-05-26 |