Provider Demographics
NPI:1447517966
Name:KOTAK, SHRUTI KISHORBHAI (PT)
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:KISHORBHAI
Last Name:KOTAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT STE 203
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1673
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:
Practice Address - Street 1:8609 SUDLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4500
Practice Address - Country:US
Practice Address - Phone:703-366-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist