Provider Demographics
NPI:1790013878
Name:RAJA, PAVITHRA (PT & PA-C)
Entity Type:Individual
Prefix:
First Name:PAVITHRA
Middle Name:
Last Name:RAJA
Suffix:
Gender:F
Credentials:PT & PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22134 HAYNES AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39465 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1600
Practice Address - Country:US
Practice Address - Phone:248-859-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014933225100000X
MI5601011408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist