Provider Demographics
NPI:1679019780
Name:SHETTY, NIKITA
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:SHETTY
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 1:42184 GLADWIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2404
Mailing Address - Country:US
Mailing Address - Phone:248-513-2471
Mailing Address - Fax:
Practice Address - Street 1:33146 RYAN RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6462
Practice Address - Country:US
Practice Address - Phone:586-883-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist