| NPI | 1043875248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0855X Clinic/Center, Adolescent and Children Mental Health (Licence: VA 3329-05-001) |
| Additional Taxonomies | 261QM0855X Clinic/Center, Adolescent and Children Mental Health (Licence: VA 3329) |
| Enumeration Date | 2019-05-03 |
| Last Update Date | 2024-01-12 |