Provider Demographics
NPI:1639211410
Name:MAHANT, BHAIRAVI
Entity Type:Individual
Prefix:
First Name:BHAIRAVI
Middle Name:
Last Name:MAHANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAVI
Other - Middle Name:
Other - Last Name:MAHANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:8192 GALWAY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2397
Mailing Address - Country:US
Mailing Address - Phone:651-739-8108
Mailing Address - Fax:651-254-0910
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist