Provider Demographics
NPI:1578176335
Name:YENUGA, SREE SUSHMA (RPT)
Entity Type:Individual
Prefix:MRS
First Name:SREE
Middle Name:SUSHMA
Last Name:YENUGA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WIDENER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-3233
Mailing Address - Country:US
Mailing Address - Phone:940-312-2759
Mailing Address - Fax:
Practice Address - Street 1:1950 RIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2243
Practice Address - Country:US
Practice Address - Phone:574-291-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010225A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist