| NPI | 1982171112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 175T00000X Peer Specialist (Licence: VA 0711000334) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0711000334) |
| Enumeration Date | 2018-10-25 |
| Last Update Date | 2018-10-25 |