| NPI | 1104225754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2014-08-20 |
| Last Update Date | 2014-08-20 |