| NPI | 1619763323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 25-CRM-4214) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-25-5479) |
| Enumeration Date | 2025-04-17 |
| Last Update Date | 2025-10-21 |