| NPI | 1760850549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 15-PRC-004) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR 11-09-48) |
| Enumeration Date | 2015-09-09 |
| Last Update Date | 2015-09-09 |