| NPI | 1184094013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2015-10-05 |
| Last Update Date | 2015-10-05 |