Provider Demographics
NPI:1912596578
Name:DEVATHALA, SHINY
Entity Type:Individual
Prefix:
First Name:SHINY
Middle Name:
Last Name:DEVATHALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8508 LOCH RAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2354
Mailing Address - Country:US
Mailing Address - Phone:443-469-3426
Mailing Address - Fax:410-256-0564
Practice Address - Street 1:8508 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-2354
Practice Address - Country:US
Practice Address - Phone:929-526-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist