| NPI | 1568006690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 12925) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC P22151) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 1086) | |
| Enumeration Date | 2019-11-01 |
| Last Update Date | 2025-06-26 |