| NPI | 1164107496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-06-15 |
| Last Update Date | 2024-10-03 |