| NPI | 1760004204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225400000X Rehabilitation Practitioner |
| Additional Taxonomies | 101Y00000X Counselor |
| 171M00000X Case Manager/Care Coordinator | |
| 172V00000X Community Health Worker | |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2020-05-06 |
| Last Update Date | 2025-05-21 |