| NPI | 1487052080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children |
| Additional Taxonomies | 101Y00000X Counselor |
| 175T00000X Peer Specialist | |
| 251S00000X Community/Behavioral Health | |
| Enumeration Date | 2014-12-12 |
| Last Update Date | 2014-12-12 |