| NPI | 1063890341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children (Licence: WY 020407A2) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2015-05-07 |
| Last Update Date | 2015-05-07 |