Provider Demographics
NPI:1699026542
Name:SAMUDRALA, LEELA
Entity Type:Individual
Prefix:
First Name:LEELA
Middle Name:
Last Name:SAMUDRALA
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 1:4720 E COTTON GIN LOOP
Mailing Address - Street 2:STE 140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-4823
Mailing Address - Country:US
Mailing Address - Phone:602-567-9881
Mailing Address - Fax:
Practice Address - Street 1:4720 E COTTON GIN LOOP
Practice Address - Street 2:STE 140
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-4823
Practice Address - Country:US
Practice Address - Phone:602-567-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8809A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant