Provider Demographics
NPI:1063814309
Name:GUDAVALLI, LAKSHMI KALYANI (PT)
Entity Type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:KALYANI
Last Name:GUDAVALLI
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 1:2834 VILLA CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7554
Mailing Address - Country:US
Mailing Address - Phone:563-639-2486
Mailing Address - Fax:
Practice Address - Street 1:275 E CARL SANDBURG DRIVE
Practice Address - Street 2:MARIGOLD REHABILITATION
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-344-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700203572251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic