| NPI | 1689342164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NM CTB-2026-0203) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: NM 1207) |
| Enumeration Date | 2021-08-31 |
| Last Update Date | 2026-07-08 |