| NPI | 1043856602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 39846) |
| Additional Taxonomies | 2251P0200X Physical Therapist, Pediatrics (Licence: MA 24669) |
| Enumeration Date | 2019-11-19 |
| Last Update Date | 2025-08-16 |