| NPI | 1568230902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 322D00000X Residential Treatment Facility, Emotionally Disturbed Children |
| Additional Taxonomies | 251S00000X |
| 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2023-12-14 |
| Last Update Date | 2023-12-14 |