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General NPI Number Information
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NPI Number | 1720660525
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Entity Type | Individual
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Provider Name | PRAJAKTA KUDALKAR PT
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Gender | Female
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Dates
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Enumeration Date | 04/22/2021
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 1241 E MAIN ST
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City | CARBONDALE
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State | IL
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Zip | 62901-3149
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Country | US
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Telephone | 618-529-0516
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Fax | 618-529-0403
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Provider Business Mailing Address
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Address Line | 1200 BLACK DIAMOND DR APT 8
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City | CARBONDALE
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State | IL
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Zip | 62901-5168
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Country | US
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Telephone | 269-276-6542
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 14808-24
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.025054
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License Number State | IL
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