| NPI | 1790505865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 24-CRM-3777) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: OR 25-QMHA-R-7845) |
| Enumeration Date | 2024-10-14 |
| Last Update Date | 2025-11-11 |