| NPI | 1104669316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 106S00000X Behavior Technician (Licence: FL BACB1062708) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 2593) |
| Enumeration Date | 2024-06-15 |
| Last Update Date | 2025-09-09 |