Provider Demographics
NPI:1780059527
Name:SHALOM THERAPEUTIC SERVICES LLC
Entity type:Organization
Organization Name:SHALOM THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PRATHIBHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTUMUKKALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-609-7155
Mailing Address - Street 1:2245 US HIGHWAY 130 STE 105
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08810-2420
Mailing Address - Country:US
Mailing Address - Phone:732-609-7155
Mailing Address - Fax:
Practice Address - Street 1:2245 US HIGHWAY 130 STE 105
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08810-2420
Practice Address - Country:US
Practice Address - Phone:732-609-7155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01534600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy