| NPI | 1154073591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OH 003182) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 179103) |
| Enumeration Date | 2022-01-26 |
| Last Update Date | 2023-07-05 |