Provider Demographics
NPI:1003205493
Name:SHAH, POOJA (PT)
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 KINGSTON CT
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1478
Mailing Address - Country:US
Mailing Address - Phone:317-900-6794
Mailing Address - Fax:
Practice Address - Street 1:1514 KINGSTON CT
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1478
Practice Address - Country:US
Practice Address - Phone:317-900-6794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021152225100000X
IN05011595A225100000X
NY037684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist