| NPI | 1689412306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 252Y00000X Early Intervention Provider Agency |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: WV 001018) |
| Enumeration Date | 2024-07-17 |
| Last Update Date | 2024-11-07 |