| NPI | 1659088821 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator | 
| Additional Taxonomies | 251S00000X Community/Behavioral Health | 
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2022-10-27 | 
| Last Update Date | 2025-07-23 |