Provider Demographics
NPI:1467187690
Name:SATHRI JEDEDIAH, HARISH (PT)
Entity Type:Individual
Prefix:
First Name:HARISH
Middle Name:
Last Name:SATHRI JEDEDIAH
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 1:1595 BEACHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-5881
Mailing Address - Country:US
Mailing Address - Phone:586-219-1290
Mailing Address - Fax:
Practice Address - Street 1:12855 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1744
Practice Address - Country:US
Practice Address - Phone:586-219-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist