Healthcare Provider Details

I. General information

NPI: 1750314951
Provider Name (Legal Business Name): SHOBA JANAKI RAJAMANNAR-UNDERHILL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
JAMAICA PLAIN MA
02130-4817
US

IV. Provider business mailing address

172 W CANTON ST # 2
BOSTON MA
02118-1216
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-6093
  • Fax: 857-364-4513
Mailing address:
  • Phone: 857-753-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17400
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: