| NPI | 1740730498 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SD 2642) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT5914) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2016-10-06 |
| Last Update Date | 2023-12-22 |