Provider Demographics
NPI:1306028055
Name:REDDY, PRAVEEN KUMAR
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:REDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 HUBBARD DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4155
Mailing Address - Country:US
Mailing Address - Phone:313-593-1703
Mailing Address - Fax:313-593-1939
Practice Address - Street 1:16200 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4155
Practice Address - Country:US
Practice Address - Phone:313-593-1703
Practice Address - Fax:313-593-1939
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist