Provider Demographics
NPI:1336674605
Name:KOTHAKONDA, VIJITHA
Entity Type:Individual
Prefix:
First Name:VIJITHA
Middle Name:
Last Name:KOTHAKONDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 LEHIGH DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:925-689-7457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist