| NPI | 1871043026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X (Licence: DC 11215-264) |
| Additional Taxonomies | 251B00000X Case Management (Licence: DC 11215-264) |
| 252Y00000X Early Intervention Provider Agency (Licence: DC 11215-264) | |
| Enumeration Date | 2016-10-12 |
| Last Update Date | 2016-10-12 |