Provider Demographics
NPI:1083053102
Name:SULE, PRAJAKTA
Entity Type:Individual
Prefix:
First Name:PRAJAKTA
Middle Name:
Last Name:SULE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 GRANT AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-2502
Mailing Address - Country:US
Mailing Address - Phone:678-429-4855
Mailing Address - Fax:
Practice Address - Street 1:672 OLD MILL RD
Practice Address - Street 2:SUITE I
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1363
Practice Address - Country:US
Practice Address - Phone:410-729-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD242482251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic