| NPI | 1720782121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR THW000109078) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-23-3395) | |
| Enumeration Date | 2023-03-29 |
| Last Update Date | 2023-12-14 |