Provider Demographics
NPI:1538776646
Name:SHAHI, SAM (DPT)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SHAHI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18440 HATTERAS ST APT 67
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1981
Mailing Address - Country:US
Mailing Address - Phone:310-621-9195
Mailing Address - Fax:
Practice Address - Street 1:18440 HATTERAS ST APT 67
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1981
Practice Address - Country:US
Practice Address - Phone:310-621-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty