Provider Demographics
NPI:1497161871
Name:NALLAN CHAKRAVARTHULA, KAUMUDI (PT)
Entity Type:Individual
Prefix:
First Name:KAUMUDI
Middle Name:
Last Name:NALLAN CHAKRAVARTHULA
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 1:24776 W WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31370 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2450
Practice Address - Country:US
Practice Address - Phone:586-285-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist