Provider Demographics
NPI:1558765453
Name:RAYCHOUDHURY, MOUMITA
Entity Type:Individual
Prefix:
First Name:MOUMITA
Middle Name:
Last Name:RAYCHOUDHURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 OAK GLEN DR
Mailing Address - Street 2:G
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3257
Mailing Address - Country:US
Mailing Address - Phone:716-262-5844
Mailing Address - Fax:
Practice Address - Street 1:303 N.HURSTBOURNE PARKWAY
Practice Address - Street 2:SUITE 200 PARAGON REHABILITATION
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011586A225100000X
MI5501016901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist