| NPI | 1982197737 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JUSTIN BRENT WALLEN Business Manager 502-319-3105 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 103T00000X Psychologist |
| Enumeration Date | 2018-06-07 |
| Last Update Date | 2021-06-16 |