Provider Demographics
NPI:1558821801
Name:BANWAT, SHAKTI
Entity Type:Individual
Prefix:
First Name:SHAKTI
Middle Name:
Last Name:BANWAT
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 1:1534 119TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-1733
Mailing Address - Country:US
Mailing Address - Phone:219-655-5285
Mailing Address - Fax:
Practice Address - Street 1:1534 119TH ST
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1733
Practice Address - Country:US
Practice Address - Phone:219-655-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006962225200000X
IN06005015A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant