| NPI | 1679283840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225400000X Rehabilitation Practitioner |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 175T00000X Peer Specialist | |
| Enumeration Date | 2022-11-29 |
| Last Update Date | 2025-09-08 |