| NPI | 1164023578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: MI DP-C) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| Enumeration Date | 2020-11-03 |
| Last Update Date | 2023-12-29 |