| NPI | 1083330682 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AISHA LYNN DEPRIEST Director Of Credentialing 844-646-3247 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2022-10-14 |
| Last Update Date | 2022-10-14 |