Provider Demographics
NPI:1831638733
Name:BANJAN, SHRUTHI KRISHNA (PT)
Entity Type:Individual
Prefix:
First Name:SHRUTHI
Middle Name:KRISHNA
Last Name:BANJAN
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 1:484, 67 ST
Mailing Address - Street 2:APT B5
Mailing Address - City:BROOKLYN, NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4901
Mailing Address - Country:US
Mailing Address - Phone:317-457-0991
Mailing Address - Fax:
Practice Address - Street 1:1312 38TH ST
Practice Address - Street 2:L'REFUAH MEDICAL & REHABILITATION CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3612
Practice Address - Country:US
Practice Address - Phone:718-686-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040837225100000X
NJ40QA01656700225100000X
FLPT30845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist