| NPI | 1114393394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MO 2015033738) |
| Enumeration Date | 2015-08-11 |
| Last Update Date | 2016-07-05 |