| NPI | 1730754581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| 322D00000X Residential Treatment Facility, Emotionally Disturbed Children | |
| 323P00000X Psychiatric Residential Treatment Facility | |
| 385HR2060X Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child | |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2022-12-30 |