| NPI | 1699030148 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VT 040.0086483) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 104.0087828) |
| Enumeration Date | 2012-07-11 |
| Last Update Date | 2012-07-11 |