Provider Demographics
NPI:1134269251
Name:DEVASTHALI, SEEMA S (PT)
Entity type:Individual
Prefix:
First Name:SEEMA
Middle Name:S
Last Name:DEVASTHALI
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:PO BOX 53605
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-3605
Mailing Address - Country:US
Mailing Address - Phone:910-223-0729
Mailing Address - Fax:910-223-0733
Practice Address - Street 1:2125 VALLEYGATE DR
Practice Address - Street 2:SUITE 101-A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3657
Practice Address - Country:US
Practice Address - Phone:910-223-0729
Practice Address - Fax:910-223-0733
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28434OtherBCBS OF NORTH CAROLINA
NC4191OtherBOARD OF PHYSICAL THERAPY
NC28434OtherBCBS OF NORTH CAROLINA