| NPI | 1912304734 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility (Licence: OR 12-crm-070) | 
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: OR 175T00000X - Peer) | 
| 101YA0400X Counselor, Addiction (Substance Use Disorder) | |
| Enumeration Date | 2014-11-21 | 
| Last Update Date | 2025-09-16 |