| NPI | 1295303444 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELISSA RUSSELL WAGNER Clinical Director 980-474-0117 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QM0850X Clinic/Center Adult Mental Health |
| Additional Taxonomies | 261QM0855X Clinic/Center Adolescent and Children Mental Health |
| 261QR0405X Clinic/Center Rehabilitation, Substance Use Disorder | |
| Enumeration Date | 2021-06-15 |
| Last Update Date | 2023-09-06 |