| NPI | 1962118612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: OH 183256) |
| Additional Taxonomies | 175T00000X Peer Specialist |
| Enumeration Date | 2023-01-26 |
| Last Update Date | 2024-06-27 |