| NPI | 1104512219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator |
| Additional Taxonomies | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Enumeration Date | 2023-04-12 |
| Last Update Date | 2023-05-05 |