Provider Demographics
NPI:1205200615
Name:ETHIRAJAN, PADMAPRIYA
Entity Type:Individual
Prefix:
First Name:PADMAPRIYA
Middle Name:
Last Name:ETHIRAJAN
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 1:6767 HOUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1542
Mailing Address - Country:US
Mailing Address - Phone:989-315-8617
Mailing Address - Fax:
Practice Address - Street 1:110 E HURON AVE STE B
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1312
Practice Address - Country:US
Practice Address - Phone:989-269-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist