| NPI | 1417401191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 3134490) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX TX8176) |
| Enumeration Date | 2016-08-10 |
| Last Update Date | 2026-05-19 |