Provider Demographics
NPI:1275022840
Name:DATLA, GOWTAMI (PT)
Entity Type:Individual
Prefix:MISS
First Name:GOWTAMI
Middle Name:
Last Name:DATLA
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 1:5100 PHEASANT RUN DR APT 2
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-6361
Mailing Address - Country:US
Mailing Address - Phone:313-819-1015
Mailing Address - Fax:
Practice Address - Street 1:515 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4316
Practice Address - Country:US
Practice Address - Phone:313-819-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist