Provider Demographics
NPI:1992161194
Name:PRADHAN, SHRUTI ANVAY (PT, DPT, MS)
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:ANVAY
Last Name:PRADHAN
Suffix:
Gender:F
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1843
Mailing Address - Country:US
Mailing Address - Phone:941-993-9249
Mailing Address - Fax:
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-993-9249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 30996222Q00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016465400Medicaid