Provider Demographics
NPI:1386003606
Name:KODUVATH, BRIGHTY SARA
Entity Type:Individual
Prefix:
First Name:BRIGHTY
Middle Name:SARA
Last Name:KODUVATH
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 1:5211 MARSH RD.
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8854
Mailing Address - Country:US
Mailing Address - Phone:517-515-3763
Mailing Address - Fax:
Practice Address - Street 1:5211 MARSH RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1106
Practice Address - Country:US
Practice Address - Phone:517-319-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist