Basic Information
| Provider Information | |||||||||
| NPI: | 1053503219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIVATSAN | ||||||||
| FirstName: | VAISHNAVI | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4049 FAIRLANE DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483013126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486139724 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5500 AUTO CLUB DR | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139828266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501012912 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.