| NPI | 1780163329 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA CP039722T) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 225100000X Physical Therapist (Licence: IA 111573) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2025-01-24 |