| NPI | 1972143915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MD R189215) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| 363L00000X Nurse Practitioner (Licence: MD R189215) | |
| Enumeration Date | 2020-01-07 |
| Last Update Date | 2025-06-13 |