| NPI | 1396062873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: OK 77-0700929) |
| Enumeration Date | 2010-04-23 |
| Last Update Date | 2010-04-23 |