| NPI | 1215413331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 172V00000X Community Health Worker |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 172V00000X Community Health Worker | |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) | |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2023-05-19 |