| NPI | 1144948274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0401X Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) | |
| 175T00000X Peer Specialist | |
| Enumeration Date | 2022-08-15 |
| Last Update Date | 2022-11-23 |