| NPI | 1104332196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: LA 2203783163) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2017-12-28 |
| Last Update Date | 2018-09-05 |