Provider Demographics
NPI:1992239586
Name:KANTAWALA, NAMITA
Entity type:Individual
Prefix:
First Name:NAMITA
Middle Name:
Last Name:KANTAWALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD,
Mailing Address - Street 2:
Mailing Address - City:BOOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5431 PATRICK WAY SUITE 101
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3934
Practice Address - Country:US
Practice Address - Phone:205-508-2277
Practice Address - Fax:205-997-2117
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26331225100000X
AL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist