| NPI | 1073059622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR THW2315) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-18-016) |
| Enumeration Date | 2017-01-06 |
| Last Update Date | 2019-05-01 |