| NPI | 1962858936 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANNON PETROVICH Owner 520-909-4740 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: AZ LCSW 4024) |
| Additional Taxonomies | 251S00000X (Licence: AZ LISAC 1365) |
| Enumeration Date | 2016-05-10 |
| Last Update Date | 2016-05-10 |