| NPI | 1376030932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 261QM0850X Clinic/Center Adult Mental Health |
| 261QM0855X Clinic/Center Adolescent and Children Mental Health | |
| Enumeration Date | 2018-04-19 |
| Last Update Date | 2025-04-28 |