Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 070.019638 | IL |
NPI | 1063769487 |
---|---|
Provider Name | Siddhi Virendra Bavishi |
First Address | Crystal Lake, IL 60014-1725 |
Second Address | Crystal Lake, IL 60014-1725 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2012 |
Last Update Date | 13/12/2012 |