Provider Demographics
NPI:1740948090
Name:BRAHMBHATT, SHAIL (PT)
Entity type:Individual
Prefix:
First Name:SHAIL
Middle Name:
Last Name:BRAHMBHATT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 BRIDGEDALE RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8696
Mailing Address - Country:US
Mailing Address - Phone:815-319-1080
Mailing Address - Fax:
Practice Address - Street 1:1436 BRIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8696
Practice Address - Country:US
Practice Address - Phone:815-319-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15647-24225100000X
IL070.026338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist