| NPI | 1396320172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 252Y00000X Early Intervention Provider Agency (Licence: NY 1477280212) |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency (Licence: NY 1363021191) |
| Enumeration Date | 2021-03-13 |
| Last Update Date | 2021-03-24 |