| NPI | 1699338681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 15CGRM001) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: OR G171102) |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2019-04-16 |