Provider Demographics
NPI:1992186472
Name:MITHBAVKAR, PRAJAKTA PRAKASH (PT, MS)
Entity Type:Individual
Prefix:MISS
First Name:PRAJAKTA
Middle Name:PRAKASH
Last Name:MITHBAVKAR
Suffix:
Gender:F
Credentials:PT, MS
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Other - First Name:
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Mailing Address - Street 1:201 WICKHAM WAY
Mailing Address - Street 2:APT # T2
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-2522
Mailing Address - Country:US
Mailing Address - Phone:781-499-8164
Mailing Address - Fax:
Practice Address - Street 1:201 WICKHAM WAY
Practice Address - Street 2:APT # T2
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-2522
Practice Address - Country:US
Practice Address - Phone:781-499-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist