| NPI | 1912874546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| 175T00000X Peer Specialist | |
| Enumeration Date | 2025-10-20 |
| Last Update Date | 2025-10-26 |