| NPI | 1073959128 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TYRONE WAGNER Owner 877-315-8080 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YM0800X Counselor, Mental Health | |
| 103K00000X Behavior Analyst | |
| Enumeration Date | 2013-05-16 |
| Last Update Date | 2016-06-15 |