Provider Demographics
NPI:1053963637
Name:MANGALORE, SHRUTI PRAMOD (MPT)
Entity type:Individual
Prefix:MISS
First Name:SHRUTI
Middle Name:PRAMOD
Last Name:MANGALORE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2368 YAKIMA AVE UNIT 525
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3917
Mailing Address - Country:US
Mailing Address - Phone:919-268-3108
Mailing Address - Fax:
Practice Address - Street 1:1720 E 67TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4223
Practice Address - Country:US
Practice Address - Phone:253-474-1741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60310605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist