| NPI | 1104620426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CA 1231146885) |
| Additional Taxonomies | 103K00000X Behavior Analyst (Licence: CA 1231132428) |
| 133N00000X Nutritionist (Licence: CA 1231147803) | |
| Enumeration Date | 2025-04-03 |
| Last Update Date | 2025-04-03 |