| NPI | 1023614310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 23261) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL 39963) |
| Enumeration Date | 2020-12-10 |
| Last Update Date | 2025-10-07 |