Healthcare Provider Details

I. General information

NPI: 1104112481
Provider Name (Legal Business Name): MONIKA GUPTA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 S SAGINAW RD
MIDLAND MI
48640-4664
US

IV. Provider business mailing address

PO BOX 3497
STURTEVANT WI
53177-0300
US

V. Phone/Fax

Practice location:
  • Phone: 866-625-3570
  • Fax: 866-245-8064
Mailing address:
  • Phone: 888-201-1040
  • Fax: 866-245-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: