Provider Demographics
NPI:1912449117
Name:BANSIL, RELLIE (PT)
Entity Type:Individual
Prefix:
First Name:RELLIE
Middle Name:
Last Name:BANSIL
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 1:11980 ISELLE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7132
Mailing Address - Country:US
Mailing Address - Phone:936-229-6231
Mailing Address - Fax:
Practice Address - Street 1:11602 LAKE UNDERHILL RD
Practice Address - Street 2:STE 129
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4458
Practice Address - Country:US
Practice Address - Phone:407-277-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 30893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEJ1-0003075OtherEXAMINING BOARD OF PHYSICAL THERAPISTS AND ATHLETIC TRAINERS
FLPT 30893OtherFLORIDA BOARD OF PHYSICAL THERAPY