Provider Demographics
NPI:1467519553
Name:TEKUMULLA, SUSHREE (OT)
Entity Type:Individual
Prefix:MRS
First Name:SUSHREE
Middle Name:
Last Name:TEKUMULLA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4136
Mailing Address - Country:US
Mailing Address - Phone:810-966-9102
Mailing Address - Fax:810-966-9104
Practice Address - Street 1:1702 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4136
Practice Address - Country:US
Practice Address - Phone:810-966-9102
Practice Address - Fax:810-966-9104
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003768225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4859304Medicaid
MIP28300001Medicare ID - Type UnspecifiedWPS MEDICARE