| NPI | 1790190023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 172V00000X Community Health Worker (Licence: CA 1457) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: CA 1457) |
| Enumeration Date | 2014-06-25 |
| Last Update Date | 2019-01-24 |