Provider Demographics
NPI:1346736543
Name:SURYA, SHRUTI (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHRUTI
Middle Name:
Last Name:SURYA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2661
Practice Address - Country:US
Practice Address - Phone:979-691-3300
Practice Address - Fax:979-691-3527
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X, 390200000X
TX38571103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program