| NPI | 1821638271 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: MD BH001887) |
| Enumeration Date | 2020-01-14 |
| Last Update Date | 2020-01-14 |