Healthcare Provider Details

I. General information

NPI: 1346998309
Provider Name (Legal Business Name): VENU GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21602 9TH AVE SE # A101
BOTHELL WA
98021-7637
US

IV. Provider business mailing address

21602 9TH AVE SE # A101
BOTHELL WA
98021-7637
US

V. Phone/Fax

Practice location:
  • Phone: 425-898-3220
  • Fax:
Mailing address:
  • Phone: 425-898-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60870125
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: