Provider Demographics
NPI:1417100603
Name:GUPTA, ANTIMA (DPT, CLT)
Entity Type:Individual
Prefix:MRS
First Name:ANTIMA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19789 PIERSON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2652
Mailing Address - Country:US
Mailing Address - Phone:248-631-6674
Mailing Address - Fax:
Practice Address - Street 1:5245 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3257
Practice Address - Country:US
Practice Address - Phone:248-631-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty