Provider Demographics
NPI:1669833372
Name:GANGWANI, PRIYA (PT)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:GANGWANI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PRIYA
Other - Middle Name:
Other - Last Name:MOHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7541
Practice Address - Fax:317-963-7079
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008658A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0500865AOtherPHYSICAL THERAPIST
IN201348810Medicaid