| NPI | 1861962094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MI 6803086847) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| Enumeration Date | 2018-11-30 |
| Last Update Date | 2023-03-17 |