| NPI | 1982252417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: FL 11015652) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9394550) |
| Enumeration Date | 2019-08-28 |
| Last Update Date | 2021-10-04 |