| NPI | 1104538016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator |
| Additional Taxonomies | 175T00000X Peer Specialist |
| 251S00000X Community/Behavioral Health | |
| Enumeration Date | 2022-12-22 |
| Last Update Date | 2025-07-16 |