| NPI | 1285034942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X (Licence: VA 0701005314) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: VA 0701005314) |
| 322D00000X Residential Treatment Facility, Emotionally Disturbed Children (Licence: VA 0701005314) | |
| Enumeration Date | 2014-09-01 |
| Last Update Date | 2014-09-01 |