| NPI | 1164776589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WV DP02943125) |
| Additional Taxonomies | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children (Licence: WV dp02943125) |
| Enumeration Date | 2012-11-07 |
| Last Update Date | 2021-04-20 |