| NPI | 1275031163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 101Y00000X Counselor |
| 175T00000X Peer Specialist | |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2018-05-04 |