| 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 | 2025-08-21 |