| NPI | 1649741521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501014242) |
| Additional Taxonomies | 225800000X Recreation Therapist (Licence: MI 5501014242) |
| Enumeration Date | 2018-12-17 |
| Last Update Date | 2018-12-17 |