| NPI | 1366815664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: PA BH001699) |
| Enumeration Date | 2015-11-09 |
| Last Update Date | 2015-11-09 |