Provider Demographics
NPI:1639834096
Name:SUKRUTHAM, SIRISHA R
Entity Type:Individual
Prefix:
First Name:SIRISHA
Middle Name:R
Last Name:SUKRUTHAM
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 1:2300 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-1116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 WARREN ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-1116
Practice Address - Country:US
Practice Address - Phone:541-686-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17145235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist