Provider Demographics
NPI:1699943365
Name:SHETTY, SAHANA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:SAHANA
Middle Name:
Last Name:SHETTY
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4659 QUIGG DR APT 753
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-8310
Mailing Address - Country:US
Mailing Address - Phone:317-383-6504
Mailing Address - Fax:
Practice Address - Street 1:4650 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9407
Practice Address - Country:US
Practice Address - Phone:707-546-0471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34433225100000X
MI5501012532225100000X
IN05008820A225100000X
NY029455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist