Provider Demographics
NPI:1447748009
Name:PRABHAKAR, SHAILLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHAILLY
Middle Name:
Last Name:PRABHAKAR
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13251 E 10 MILE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2000
Mailing Address - Country:US
Mailing Address - Phone:586-759-7474
Mailing Address - Fax:586-759-7476
Practice Address - Street 1:13251 E 10 MILE RD STE 400
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2000
Practice Address - Country:US
Practice Address - Phone:586-759-7474
Practice Address - Fax:586-759-7476
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist