| NPI | 1114679263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: WA CG61265234) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2022-01-20 |
| Last Update Date | 2022-06-01 |