| NPI | 1457187320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Enumeration Date | 2024-09-09 |
| Last Update Date | 2025-09-03 |