Provider Demographics
NPI:1720660525
Name:KUDALKAR, PRAJAKTA (PT)
Entity Type:Individual
Prefix:
First Name:PRAJAKTA
Middle Name:
Last Name:KUDALKAR
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 1:1200 BLACK DIAMOND DR APT 8
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5168
Mailing Address - Country:US
Mailing Address - Phone:269-276-6542
Mailing Address - Fax:
Practice Address - Street 1:1241 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3149
Practice Address - Country:US
Practice Address - Phone:618-529-0516
Practice Address - Fax:618-529-0403
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14808-24225100000X
IL070.025054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist