Provider Demographics
NPI:1417362930
Name:DEVALLA, RAJ (PT)
Entity Type:Individual
Prefix:
First Name:RAJ
Middle Name:
Last Name:DEVALLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BERGERS CT E
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-1518
Mailing Address - Country:US
Mailing Address - Phone:631-891-9936
Mailing Address - Fax:
Practice Address - Street 1:35 BERGERS CT E
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-1518
Practice Address - Country:US
Practice Address - Phone:631-891-9936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist