| NPI | 1124660956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: FL 11040467) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-10-14 |
| Last Update Date | 2025-07-29 |