Provider Demographics
NPI:1417420449
Name:MUTTIREVULA, THAPASVI (PT)
Entity Type:Individual
Prefix:
First Name:THAPASVI
Middle Name:
Last Name:MUTTIREVULA
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 1:2422 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083
Mailing Address - Country:US
Mailing Address - Phone:586-488-8123
Mailing Address - Fax:586-314-0181
Practice Address - Street 1:2422 CEDAR KNOLL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:586-488-8123
Practice Address - Fax:586-314-0181
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist