Basic Information
| Provider Information | |||||||||
| NPI: | 1891416806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHODIYA | ||||||||
| FirstName: | GRACE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13507 WILLIAM BEANES RD | ||||||||
| Address2: | |||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207724005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1240595381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2875 CRAIN HWY | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018593304 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2022 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.