| NPI | 1508293390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: KS 200392920a) |
| Additional Taxonomies | 251C00000X (Licence: KS 200392920a) |
| Enumeration Date | 2013-10-11 |
| Last Update Date | 2013-10-11 |