| NPI | 1831484278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder (Licence: FL MT2632) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: FL MT2632) |
| 103K00000X Behavior Analyst (Licence: FL 251S00000X) | |
| Enumeration Date | 2011-06-14 |
| Last Update Date | 2026-08-04 |