| NPI | 1962923375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11027912) |
| Additional Taxonomies | 103K00000X Behavior Analyst (Licence: FL 1-21-53906) |
| 106E00000X Assistant Behavior Analyst (Licence: FL 0-19-10541) | |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 17-360) | |
| Enumeration Date | 2017-07-06 |
| Last Update Date | 2024-03-27 |