Provider Demographics
NPI:1265123152
Name:DATTA, ADITI SURYAKANT (PT)
Entity type:Individual
Prefix:
First Name:ADITI
Middle Name:SURYAKANT
Last Name:DATTA
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 1:402 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6044
Mailing Address - Country:US
Mailing Address - Phone:817-733-6708
Mailing Address - Fax:
Practice Address - Street 1:4600 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2320
Practice Address - Country:US
Practice Address - Phone:574-282-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010293A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist