| NPI | 1679164107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2021-01-27 |
| Last Update Date | 2026-04-03 |