Provider Demographics
NPI:1659628709
Name:MOHANTY, EVA (DPT)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:MOHANTY
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 1:608 MERRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2535
Mailing Address - Country:US
Mailing Address - Phone:732-910-3995
Mailing Address - Fax:
Practice Address - Street 1:608 MERRYWOOD DR
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2535
Practice Address - Country:US
Practice Address - Phone:732-910-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01061600174400000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency