| NPI | 1982133120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 174400000X Specialist |
| 251V00000X Voluntary or Charitable | |
| 374K00000X Religious Nonmedical Practitioner | |
| Enumeration Date | 2017-06-10 |
| Last Update Date | 2017-06-10 |