| NPI | 1558056317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1368121) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: RI PT04057) |
| Enumeration Date | 2023-04-07 |
| Last Update Date | 2025-09-12 |