| NPI | 1114632809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| 324500000X Substance Abuse Rehabilitation Facility | |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) | |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) | |
| Enumeration Date | 2023-01-18 |
| Last Update Date | 2023-01-18 |