| NPI | 1225708068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: MD 210811438) |
| Enumeration Date | 2021-09-14 |
| Last Update Date | 2021-09-14 |