Provider Demographics
NPI:1467916023
Name:SRINIVASARAGAVAN, EMILY VITTAL
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:VITTAL
Last Name:SRINIVASARAGAVAN
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 1:314 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1794
Mailing Address - Country:US
Mailing Address - Phone:518-437-5700
Mailing Address - Fax:
Practice Address - Street 1:333 TURNPIKE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1755
Practice Address - Country:US
Practice Address - Phone:508-898-2688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP14757225X00000X
MA014748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist