| NPI | 1972935203 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501302377) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT023079) |
| Enumeration Date | 2013-08-09 |
| Last Update Date | 2022-12-01 |