Provider Demographics
NPI:1063661288
Name:MANDAVA, PRATHIMA (PT)
Entity Type:Individual
Prefix:MRS
First Name:PRATHIMA
Middle Name:
Last Name:MANDAVA
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 1:12947 TOWNSEND DR
Mailing Address - Street 2:# 812
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8727
Mailing Address - Country:US
Mailing Address - Phone:906-250-8223
Mailing Address - Fax:
Practice Address - Street 1:12947 TOWNSEND DR
Practice Address - Street 2:# 812
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8727
Practice Address - Country:US
Practice Address - Phone:906-250-8223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist