| NPI | 1568686509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: MI 6301001724) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301001724) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2012-01-13 |