| NPI | 1821615659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2020-06-27 |
| Last Update Date | 2020-06-27 |