| NPI | 1801535265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: LA CIT-6105) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: LA OBHPSS883) |
| Enumeration Date | 2022-06-02 |
| Last Update Date | 2026-03-11 |