| NPI | 1306327770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 251S00000X | |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2018-08-23 |