| NPI | 1972283844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: KY 4028613) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: IN 28266641A) |
| Enumeration Date | 2023-07-24 |
| Last Update Date | 2025-10-21 |