| NPI | 1962211391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: OR 10037244) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10037244) |
| Enumeration Date | 2024-12-31 |
| Last Update Date | 2025-10-15 |