| NPI | 1205530979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist |
| Additional Taxonomies | 273Y00000X Rehabilitation Unit (Licence: TX OOKBDCV) |
| 252Y00000X Early Intervention Provider Agency (Licence: TX OOKBDCV) | |
| Enumeration Date | 2023-03-28 |
| Last Update Date | 2023-03-28 |