| NPI | 1861974081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: OR 16-CRM-117) |
| Additional Taxonomies | 172V00000X Community Health Worker (Licence: OR THW-1396) |
| Enumeration Date | 2018-09-04 |
| Last Update Date | 2018-09-04 |