| NPI | 1992185524 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LAURIE BETH VIZENOR Mental Health Practitioner, Trainee 21832-711-0524 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: MN 101ym0800x) |
| Enumeration Date | 2015-06-09 |
| Last Update Date | 2015-06-09 |