| NPI | 1619846078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| 322D00000X Residential Treatment Facility, Emotionally Disturbed Children | |
| Enumeration Date | 2025-11-03 |
| Last Update Date | 2025-11-03 |