Provider Demographics
NPI:1467706598
Name:RAGHAVAN, DIVYA (PT)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:RAGHAVAN
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 1:505 W OLIVE AVE STE 468
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-7625
Mailing Address - Country:US
Mailing Address - Phone:669-241-1062
Mailing Address - Fax:
Practice Address - Street 1:505 W OLIVE AVE STE 468
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-7625
Practice Address - Country:US
Practice Address - Phone:669-241-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017535225100000X
NY034160225100000X
CA40962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist