| NPI | 1154317337 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 2284) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SD 0469) |
| 225100000X Physical Therapist (Licence: ND 483) | |
| 225100000X Physical Therapist (Licence: IA 03105) | |
| Enumeration Date | 2005-09-23 |
| Last Update Date | 2007-07-08 |