| NPI | 1962761478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: TX 1052216) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 650922) |
| Enumeration Date | 2012-05-04 |
| Last Update Date | 2022-10-23 |