| NPI | 1962870519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 101Y00000X Counselor | |
| Enumeration Date | 2015-09-11 |
| Last Update Date | 2026-09-18 |