| NPI | 1104408939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2021-04-21 |
| Last Update Date | 2025-01-13 |