| NPI | 1538991617 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 110397) | 
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-24-4057) | 
| Enumeration Date | 2024-08-16 | 
| Last Update Date | 2025-07-17 |