| NPI | 1053849828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 14775) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: CT 007864) |
| Enumeration Date | 2017-05-24 |
| Last Update Date | 2025-02-18 |