| NPI | 1356001713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 012339) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: CT 12339) |
| Enumeration Date | 2021-12-28 |
| Last Update Date | 2022-07-27 |