| NPI | 1013696012 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LATREASE R MOORE Co Owner 315-220-0603 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| 261QM0855X Clinic/Center, Adolescent and Children Mental Health | |
| Enumeration Date | 2023-07-17 |
| Last Update Date | 2023-07-27 |