| NPI | 1134745771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| 251S00000X | |
| Enumeration Date | 2020-06-19 |
| Last Update Date | 2020-06-19 |