Healthcare Provider Details

I. General information

NPI: 1720660525
Provider Name (Legal Business Name): PRAJAKTA KUDALKAR PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 E MAIN ST
CARBONDALE IL
62901-3149
US

IV. Provider business mailing address

1200 BLACK DIAMOND DR APT 8
CARBONDALE IL
62901-5168
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-0516
  • Fax: 618-529-0403
Mailing address:
  • Phone: 269-276-6542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14808-24
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.025054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: