| NPI | 1376391904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 22-CRM-1078) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-25-5276) |
| Enumeration Date | 2024-05-08 |
| Last Update Date | 2026-08-07 |