| NPI | 1639866197 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSIE COSTLEY Credentialing Specialist 443-839-6928 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health |
| Enumeration Date | 2023-04-24 |
| Last Update Date | 2025-02-28 |