| NPI | 1598644858 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 65830) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT-2025-0251) |
| Enumeration Date | 2025-08-30 |
| Last Update Date | 2025-08-30 |