| NPI | 1497979041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: MO CS000906) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MO CS000906) |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2015-07-21 |