MEDICARE: SHALOM THERAPEUTIC SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	40QA01534600	NJ

General Provider Information

NPI Number	:	1780059527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHALOM THERAPEUTIC SERVICES LLC

Provider Business Mailing Address
First Line	:	2245 US HIGHWAY 130 STE 105
Second Line	:
City	:	DAYTON
State	:	NJ
Zip	:	08810-2420
Country	:	US
Telephone Number	:	732-609-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 US HIGHWAY 130 STE 105
Second Line	:
City	:	DAYTON
State	:	NJ
Zip	:	08810-2420
Country	:	US
Telephone Number	:	732-609-7155
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	PRATHIBHA GOTTUMUKKALA
Credential	:
Telephone Number	:	732-609-7155

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	03/25/2025

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Directions to “SHALOM THERAPEUTIC SERVICES LLC ” Practice Location

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