Provider Demographics
NPI:1336208875
Name:ABRAHAM, ASHA (RPT)
Entity Type:Individual
Prefix:MRS
First Name:ASHA
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 SPRING VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405
Mailing Address - Country:US
Mailing Address - Phone:502-419-6927
Mailing Address - Fax:
Practice Address - Street 1:1518 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405
Practice Address - Country:US
Practice Address - Phone:502-419-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012263225100000X
WI11375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650H225250OtherBCBS INDIVIDUAL PIN
MI383454355OtherALTERNATIVE REHAB TAX ID
MI650H217590OtherBCBS GROUP PIN
MI650H217590OtherBCBS GROUP PIN
MIN15300011Medicare PIN