| NPI | 1255996989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM PT-2024-0154) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-05-08 |
| Last Update Date | 2024-06-25 |