Provider Demographics
NPI:1083967996
Name:GANDLA, SRILAXMI (PT)
Entity Type:Individual
Prefix:
First Name:SRILAXMI
Middle Name:
Last Name:GANDLA
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 1:24865 WOODRIDGE DR APT 212
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2256
Mailing Address - Country:US
Mailing Address - Phone:815-566-6878
Mailing Address - Fax:
Practice Address - Street 1:12123 CONANT ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-2718
Practice Address - Country:US
Practice Address - Phone:313-891-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016051225100000X
NY034869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist