| NPI | 1518563964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0401X Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
| Additional Taxonomies | 261QM0855X Clinic/Center, Adolescent and Children Mental Health |
| Enumeration Date | 2020-12-10 |
| Last Update Date | 2022-03-15 |