Healthcare Provider Details

I. General information

NPI: 1174090807
Provider Name (Legal Business Name): SHERLY REGE KUTTOTHARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 SMITH DR
ALVIN TX
77511-5562
US

IV. Provider business mailing address

7803 BLAZING GAP
MISSOURI CITY TX
77459-6037
US

V. Phone/Fax

Practice location:
  • Phone: 281-331-6125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2111543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: