Provider Demographics
NPI:1598468043
Name:BOBBALA, PAVANI
Entity Type:Individual
Prefix:
First Name:PAVANI
Middle Name:
Last Name:BOBBALA
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 1:8256 WINTERS LN
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9100
Mailing Address - Country:US
Mailing Address - Phone:832-390-9568
Mailing Address - Fax:
Practice Address - Street 1:8256 WINTERS LN
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9100
Practice Address - Country:US
Practice Address - Phone:832-390-9568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT015153261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy