| NPI | 1093289985 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGIE BOULWARE Director, Credentialing & Contract 800-288-3406 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2019-01-14 |