| NPI | 1376433532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: KY 1218179) |
| Additional Taxonomies | 172V00000X Community Health Worker |
| Enumeration Date | 2025-07-08 |
| Last Update Date | 2025-10-08 |