| NPI | 1619586310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 106H00000X Marriage & Family Therapist |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2020-07-28 |
| Last Update Date | 2020-12-04 |