| NPI | 1730710302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 172V00000X Community Health Worker (Licence: CA 172V00000X) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2020-01-31 |
| Last Update Date | 2023-06-05 |