Provider Demographics
NPI:1659984706
Name:GUPTA, MANIKA (PT)
Entity Type:Individual
Prefix:
First Name:MANIKA
Middle Name:
Last Name:GUPTA
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 1:316 WILTSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6242
Mailing Address - Country:US
Mailing Address - Phone:469-455-1797
Mailing Address - Fax:
Practice Address - Street 1:316 WILTSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-6242
Practice Address - Country:US
Practice Address - Phone:469-455-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1253766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty