| NPI | 1871139022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 14381) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| Enumeration Date | 2019-11-22 |
| Last Update Date | 2020-01-14 |