Provider Demographics
NPI:1124385901
Name:GOTTUMUKKALA, PRATHIBHA
Entity type:Individual
Prefix:
First Name:PRATHIBHA
Middle Name:
Last Name:GOTTUMUKKALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 US HIGHWAY 130 STE 105
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08810-2420
Mailing Address - Country:US
Mailing Address - Phone:732-609-7155
Mailing Address - Fax:609-228-6173
Practice Address - Street 1:2245 US HIGHWAY 130 STE 105
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08810-2420
Practice Address - Country:US
Practice Address - Phone:732-609-7155
Practice Address - Fax:609-228-6173
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01534600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist