| NPI | 1508600487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: LA OBHPSS906) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA CIT-5840) |
| Enumeration Date | 2024-06-24 |
| Last Update Date | 2024-09-24 |