| NPI | 1588104012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OH 0001998) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2017-03-02 |
| Last Update Date | 2020-09-21 |