Provider Demographics
NPI:1154869683
Name:DEVATHA, LAVANYA
Entity type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:DEVATHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAVANYA
Other - Middle Name:
Other - Last Name:DEVATHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5396 BROAD ST
Mailing Address - Street 2:APT H
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-2239
Mailing Address - Country:US
Mailing Address - Phone:443-641-7862
Mailing Address - Fax:
Practice Address - Street 1:1 OAKWOOD BLVD
Practice Address - Street 2:#130
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1956
Practice Address - Country:US
Practice Address - Phone:954-925-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT320172251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics