| NPI | 1013563287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251C00000X Day Training, Developmentally Disabled Services |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| 322D00000X Residential Treatment Facility, Emotionally Disturbed Children | |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2023-05-06 |