| NPI | 1366390072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: WA CG70040136) |
| Additional Taxonomies | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder (Licence: WA CG70040136) |
| Enumeration Date | 2026-03-18 |
| Last Update Date | 2026-03-18 |