| NPI | 1225260961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency |
| Enumeration Date | 2009-08-13 |
| Last Update Date | 2020-07-13 |