Basic Information
| Provider Information | |||||||||
| NPI: | 1902041403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CABRERA | ||||||||
| FirstName: | SRI SHERMAN | ||||||||
| MiddleName: | BACALA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3290 N RIDGE RD | ||||||||
| Address2: | SUITE 290 EXECUTIVE CENTER II | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107509006 | ||||||||
| FaxNumber: | 4107500787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3290 N RIDGE RD | ||||||||
| Address2: | SUITE 290 EXECUTIVE CENTER II | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107509006 | ||||||||
| FaxNumber: | 4107500787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 12/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 029545 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.