| NPI | 1376095091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 172V00000X Community Health Worker |
| Additional Taxonomies | 225400000X Rehabilitation Practitioner (Licence: OR 16-05-10) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 16-05-10) | |
| Enumeration Date | 2016-10-28 |
| Last Update Date | 2023-04-14 |