| NPI | 1720421795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X (Licence: WI 16862-130) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: WI 16862-130) |
| Enumeration Date | 2013-04-09 |
| Last Update Date | 2013-04-09 |