| Provider Type: | Behavioral Health & Social Service Providers |
| Provider Classification: | Psychologist |
| Provider Specialization: | Clinical |
| Address: |
749262 OLZrrCOCQd 88625, NC |
| Authorized Official: | 23809 74191, 895482 1231, 4053, 11809 |
| Authorized Official Position: | 50161 |
