| NPI | 1255823779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health (Licence: CA 235524) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: CA 235524) |
| Enumeration Date | 2018-05-31 |
| Last Update Date | 2018-05-31 |