| NPI | 1336408632 |
|---|---|
| Doing Business As | N/A |
| Entity Type | Organization |
| Authorized Contact | LISA RENEA CRUZ Owner 208-313-0711 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2084P0804X Psychiatry & Neurology, Child & Adolescent Psychiatry |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: ID M-9188) |
| 363A00000X Physician Assistant (Licence: ID PA-334) | |
| Enumeration Date | 2012-05-08 |
| Last Update Date | 2013-02-01 |