Provider Demographics
NPI:1932463270
Name:BOYA, MAMATHA REDDY (PT)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:REDDY
Last Name:BOYA
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 1:201 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2800
Mailing Address - Country:US
Mailing Address - Phone:301-987-6170
Mailing Address - Fax:
Practice Address - Street 1:201 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2800
Practice Address - Country:US
Practice Address - Phone:301-987-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2012-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist