Healthcare Provider Details

I. General information

NPI: 1053503219
Provider Name (Legal Business Name): VAISHNAVI SRIVATSAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

4049 FAIRLANE DR
BLOOMFIELD HILLS MI
48301-3126
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8266
  • Fax:
Mailing address:
  • Phone: 248-613-9724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501012912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: