| NPI | 1750804563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TR0400X Psychologist, Rehabilitation (Licence: FL PY12040) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-07-24 |
| Last Update Date | 2025-03-05 |