| NPI | 1962954982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 172V00000X Community Health Worker (Licence: MI 43) |
| 251S00000X | |
| Enumeration Date | 2016-10-25 |
| Last Update Date | 2024-03-25 |