| NPI | 1194191296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: MI 5502003688) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2015-08-12 |
| Last Update Date | 2026-03-23 |