| NPI | 1407677941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IL 31124) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: IL 31124) |
| 106H00000X Marriage & Family Therapist (Licence: IL 31124) | |
| 171M00000X Case Manager/Care Coordinator (Licence: IL 31124) | |
| 172V00000X Community Health Worker (Licence: IL 31124) | |
| 175T00000X Peer Specialist (Licence: IL 31124) | |
| 302F00000X Exclusive Provider Organization (Licence: IL 31124) | |
| 305S00000X Point of Service (Licence: IL 31124) | |
| 405300000X Prevention Professional (Licence: IL 31124) | |
| Enumeration Date | 2024-10-17 |
| Last Update Date | 2024-10-19 |