| NPI | 1366030124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: AL 4477C) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: AL ADC-907) |
| 175T00000X Peer Specialist (Licence: AL CRSS-0348) | |
| Enumeration Date | 2021-01-07 |
| Last Update Date | 2024-07-16 |