| NPI | 1245190396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: ID 13086) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: ID 13086) |
| Enumeration Date | 2025-11-12 |
| Last Update Date | 2026-03-24 |