| NPI | 1659095503 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CRYSTAL CLARK Np/Operating Agent 618-367-3732 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| 261QM0855X Clinic/Center, Adolescent and Children Mental Health | |
| Enumeration Date | 2022-10-03 |
| Last Update Date | 2022-10-03 |