| NPI | 1053173385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MD 33930) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: PA 21055) |
| Enumeration Date | 2024-01-23 |
| Last Update Date | 2025-11-13 |