| NPI | 1215791876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 23-CRM-2748) |
| Additional Taxonomies | 261QR0800X Clinic/Center Recovery Care (Licence: OR 23-CRM-2748) |
| Enumeration Date | 2024-02-13 |
| Last Update Date | 2024-02-13 |