| NPI | 1558904557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: TX 1271-0621) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: TX 50028-0820) |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2024-01-28 |