Provider Demographics
NPI:1720351604
Name:SHIVAKOTY, ANSHUMALA M
Entity Type:Individual
Prefix:
First Name:ANSHUMALA
Middle Name:M
Last Name:SHIVAKOTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9113 THISTLEDOWN RD APT 395
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-8283
Mailing Address - Country:US
Mailing Address - Phone:225-229-5145
Mailing Address - Fax:
Practice Address - Street 1:1801 WENTWORTH RD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234
Practice Address - Country:US
Practice Address - Phone:225-229-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206211225100000X
MD24749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist