| NPI | 1619754975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2023-09-11 |
| Last Update Date | 2025-05-06 |