Provider Demographics
NPI:1619246626
Name:DALAL, GEETA (PT)
Entity Type:Individual
Prefix:
First Name:GEETA
Middle Name:
Last Name:DALAL
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 1:4410 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8603
Mailing Address - Country:US
Mailing Address - Phone:810-385-6393
Mailing Address - Fax:
Practice Address - Street 1:1702 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4136
Practice Address - Country:US
Practice Address - Phone:810-966-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist