Basic Information
| Provider Information | |||||||||
| NPI: | 1477712974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALILLAS | ||||||||
| FirstName: | SHALAMAH | ||||||||
| MiddleName: | GADDI | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | N/A | ||||||||
| OtherFirstName: | N/A | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3290 N RIDGE RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107509006 | ||||||||
| FaxNumber: | 4107500787 | ||||||||
| Practice Location | |||||||||
| Address1: | 349 HAYDENVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEEDS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010539767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135867700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18125 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.