Provider Demographics
NPI:1134331572
Name:CHACKO, SHANTI K (DPT)
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:K
Last Name:CHACKO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 HARTWICK ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-2015
Mailing Address - Country:US
Mailing Address - Phone:201-873-4968
Mailing Address - Fax:
Practice Address - Street 1:33 HARTWICK ST
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-2015
Practice Address - Country:US
Practice Address - Phone:201-873-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00920200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist