| NPI | 1982230124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: IL 209.021514.041.49794) |
| Additional Taxonomies | 163WP0807X Registered Nurse, Psych/Mental Health, Child & Adolescent (Licence: OH RN.458795) |
| 163WP0808X Registered Nurse, Psych/Mental Health (Licence: IL 041.494794) | |
| Enumeration Date | 2020-03-19 |
| Last Update Date | 2021-01-29 |