| NPI | 1114637048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 104100000X Social Worker (Licence: NM SWB-2025-0826) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: NM 1353) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM CTB-2025-0172) | |
| Enumeration Date | 2022-12-01 |
| Last Update Date | 2025-07-25 |