| NPI | 1801683438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: WI 0019817) |
| Additional Taxonomies | 320700000X Residential Treatment Facility, Physical Disabilities (Licence: WI 0019817) |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities | |
| Enumeration Date | 2025-04-24 |
| Last Update Date | 2025-04-24 |