NPI | 1053987628 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
Additional Taxonomies | 261QD1600X Clinic/Center, Developmental Disabilities |
Enumeration Date | 2021-06-03 |
Last Update Date | 2022-12-14 |