Provider Demographics
NPI:1609329481
Name:VENKATESSAN, NITHIA
Entity Type:Individual
Prefix:
First Name:NITHIA
Middle Name:
Last Name:VENKATESSAN
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 1:8644 ARDENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-1837
Mailing Address - Country:US
Mailing Address - Phone:626-264-2426
Mailing Address - Fax:
Practice Address - Street 1:115 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-2719
Practice Address - Country:US
Practice Address - Phone:626-289-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist