Provider Demographics
NPI:1073901393
Name:KRISHNAN, RAJKUMAR
Entity Type:Individual
Prefix:
First Name:RAJKUMAR
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E PALM DR
Mailing Address - Street 2:APT 322
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1757
Mailing Address - Country:US
Mailing Address - Phone:909-749-9541
Mailing Address - Fax:
Practice Address - Street 1:3200 E PALM DR
Practice Address - Street 2:APT 322
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1757
Practice Address - Country:US
Practice Address - Phone:909-749-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 17426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist