| NPI | 1952432916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 008606) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 10502) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 000154) | |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2025-09-11 |