| NPI | 1588428460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 251S00000X | |
| Enumeration Date | 2024-02-12 |
| Last Update Date | 2024-02-12 |