| NPI | 1356588578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 222Q00000X Developmental Therapist |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency |
| 251S00000X | |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| Enumeration Date | 2009-01-09 |
| Last Update Date | 2015-06-10 |