Provider Demographics
NPI:1033478219
Name:RAJENDRAN, KATHIRESAN (MS,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KATHIRESAN
Middle Name:
Last Name:RAJENDRAN
Suffix:
Gender:M
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12627 SAN JOSE BLVD
Mailing Address - Street 2:STE. 506
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2662
Mailing Address - Country:US
Mailing Address - Phone:301-300-0382
Mailing Address - Fax:877-736-3470
Practice Address - Street 1:12627 SAN JOSE BLVD
Practice Address - Street 2:STE. 506
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2662
Practice Address - Country:US
Practice Address - Phone:301-300-0382
Practice Address - Fax:877-736-3470
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist