| NPI | 1669949079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225400000X Rehabilitation Practitioner |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| 251S00000X Community/Behavioral Health (Licence: CA none) | |
| Enumeration Date | 2018-10-24 |
| Last Update Date | 2025-04-21 |