| NPI | 1023851003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Enumeration Date | 2024-06-17 |
| Last Update Date | 2024-08-01 |