| NPI | 1104484955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| 171W00000X Contractor | |
| 251S00000X Community/Behavioral Health | |
| Enumeration Date | 2019-06-05 |
| Last Update Date | 2025-05-16 |