| NPI | 1770524902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IA 00123) |
| Additional Taxonomies | 221700000X Art Therapist (Licence: IA 00123) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2008-07-31 |