| NPI | 1912610569 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 373H00000X Day Training/Habilitation Specialist | 
| Additional Taxonomies | 101Y00000X Counselor | 
| 172V00000X Community Health Worker | |
| Enumeration Date | 2022-12-28 | 
| Last Update Date | 2025-06-04 |