| NPI | 1962116905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: LA 220378) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: LA 220378) |
| Enumeration Date | 2023-01-12 |
| Last Update Date | 2023-03-07 |