Provider Demographics
NPI:1932256245
Name:KUMAR, YATHISH K (PT)
Entity Type:Individual
Prefix:MR
First Name:YATHISH
Middle Name:K
Last Name:KUMAR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:YATHISH
Other - Middle Name:K
Other - Last Name:KUMAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:994 GHENT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3330
Mailing Address - Country:US
Mailing Address - Phone:248-808-4524
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 215
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932256245Medicaid
MI5501005855OtherPHYSICAL THERAPY