Provider Demographics
NPI:1578049615
Name:RAVURU, SUPRIYA
Entity Type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:RAVURU
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 1:22683 BEACON CREST TER
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6427
Mailing Address - Country:US
Mailing Address - Phone:516-279-9939
Mailing Address - Fax:
Practice Address - Street 1:12475 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2803
Practice Address - Country:US
Practice Address - Phone:703-352-7172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB69665178OtherDRIVERS LICENSE