| NPI | 1669032413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 24627) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 3124) | |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2024-08-28 |