| NPI | 1770254104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 21-CRM-603) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: OR T-21-991) |
| Enumeration Date | 2021-09-24 |
| Last Update Date | 2021-09-24 |