| NPI | 1184223802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 323P00000X Psychiatric Residential Treatment Facility (Licence: AZ bh5143) |
| Additional Taxonomies | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children (Licence: AZ Bh5143) |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) | |
| Enumeration Date | 2020-10-23 |
| Last Update Date | 2020-10-23 |