| NPI | 1467215590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| Enumeration Date | 2024-02-01 |
| Last Update Date | 2024-02-01 |