| NPI | 1134375223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: CA A34742) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: CA A34742) |
| 320800000X Community Based Residential Treatment Facility, Mental Illness (Licence: CA A347420) | |
| 323P00000X Psychiatric Residential Treatment Facility (Licence: CA a347420) | |
| 324500000X Substance Abuse Rehabilitation Facility (Licence: CA a347420) | |
| Enumeration Date | 2008-08-08 |
| Last Update Date | 2017-03-24 |