| NPI | 1205640679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 320900000X Community Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | |
| Enumeration Date | 2025-02-05 |
| Last Update Date | 2025-02-05 |