Provider Demographics
NPI:1144604562
Name:VASA, SHRADHA (PT)
Entity Type:Individual
Prefix:
First Name:SHRADHA
Middle Name:
Last Name:VASA
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 1:5691 LASATER DR NW
Mailing Address - Street 2:APT 5
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1083
Practice Address - Country:US
Practice Address - Phone:330-430-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT014138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist