| NPI | 1114725165 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JUSTIN AYCOCK Regulatory Specialist 800-441-0380 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2025-03-05 |
| Last Update Date | 2025-03-05 |