| NPI | 1720822042 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TANYA ROACH Credentialing Manager 844-843-7279 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical |
| Additional Taxonomies | 101Y00000X Counselor |
| 103T00000X Psychologist | |
| 106H00000X Marriage & Family Therapist | |
| 2084P0800X Psychiatry & Neurology, Psychiatry | |
| 363LP0808X Nurse Practitioner, Psych/Mental Health | |
| Enumeration Date | 2024-06-21 |
| Last Update Date | 2025-01-14 |