| NPI | 1396269726 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSICA BLAINE Credentialing Specialist 531-355-3362 |
| Organization Subpart ? | No |
| Primary Taxonomy | 101Y00000X Counselor |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2017-07-27 |
| Last Update Date | 2020-02-12 |