| NPI | 1962860155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: NC 5023656) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: NC 12253) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC LCAS-21369) | |
| Enumeration Date | 2016-02-03 |
| Last Update Date | 2026-07-15 |