Provider Demographics
NPI:1770302234
Name:TOMMUNDRUM, SHRESHTA (PT)
Entity type:Individual
Prefix:
First Name:SHRESHTA
Middle Name:
Last Name:TOMMUNDRUM
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 1:3465 CHIPPENDALE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-1773
Mailing Address - Country:US
Mailing Address - Phone:586-804-6777
Mailing Address - Fax:
Practice Address - Street 1:1609 VOORHIES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4092
Practice Address - Country:US
Practice Address - Phone:718-819-3928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist