| NPI | 1790455400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: AZ LAC-22014) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2021-09-14 |
| Last Update Date | 2026-02-18 |