| NPI | 1538422274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: NY 811870) |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2012-06-18 |