Provider Demographics
NPI:1659712461
Name:KURUVILLA, TISHA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:KURUVILLA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 LANSDOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 EAST STATE STREET
Practice Address - Street 2:GENESIS REHAB SERVICES
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348
Practice Address - Country:US
Practice Address - Phone:856-889-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL011127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist