| NPI | 1790430452 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JO DECK Credentialing Specialist 863-519-0575 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2022-02-21 |
| Last Update Date | 2022-02-21 |