| NPI | 1376322875 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) | 
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator | 
| 175T00000X Peer Specialist | |
| Enumeration Date | 2023-09-25 | 
| Last Update Date | 2025-06-02 |