Basic Information
| Provider Information | |||||||||
| NPI: | 1154869683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVATHA | ||||||||
| FirstName: | LAVANYA | ||||||||
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| OtherLastName: | DEVATHA | ||||||||
| OtherFirstName: | LAVANYA | ||||||||
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| OtherCredential: | P.T | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5396 BROAD ST | ||||||||
| Address2: | APT H | ||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325702239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436417862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 OAKWOOD BLVD | ||||||||
| Address2: | #130 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330201956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549253844 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2017 | ||||||||
| LastUpdateDate: | 02/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | PT32017 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.