Provider Demographics
NPI:1699909572
Name:MUKTA, SRAVANTHI (PT)
Entity type:Individual
Prefix:
First Name:SRAVANTHI
Middle Name:
Last Name:MUKTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1144
Mailing Address - Country:US
Mailing Address - Phone:231-873-3577
Mailing Address - Fax:231-873-3557
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1144
Practice Address - Country:US
Practice Address - Phone:231-873-3577
Practice Address - Fax:231-873-3557
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F410300OtherBCBS GROUP PIN #
MI650F410360OtherBCBS PIN
MI0N79320OtherMEDICARE GROUP PIN
MI0N79320OtherMEDICARE GROUP PIN