| NPI | 1104191576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225400000X Rehabilitation Practitioner |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2012-03-17 |
| Last Update Date | 2012-12-18 |