Provider Demographics
NPI:1477979912
Name:MATLAWALA, PRIYANKA (MSPT)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:MATLAWALA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:192D HALPINE RD STE D
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-7635
Practice Address - Country:US
Practice Address - Phone:240-514-2400
Practice Address - Fax:301-816-6968
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4374045-00Medicaid
MD4374045-00Medicaid
MD1447657507OtherNPI TYPE 2