Provider Demographics
NPI:1710017843
Name:MURTY-VELAMAKANNI, VIJAYA K (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:VIJAYA
Middle Name:K
Last Name:MURTY-VELAMAKANNI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:VIJAYA
Other - Middle Name:K
Other - Last Name:MURTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:22655 BAYSHORE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-2003
Mailing Address - Country:US
Mailing Address - Phone:941-766-8835
Mailing Address - Fax:941-629-1111
Practice Address - Street 1:22655 BAYSHORE RD STE 110
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2003
Practice Address - Country:US
Practice Address - Phone:941-766-8835
Practice Address - Fax:941-629-1111
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW59841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
E4035Medicare ID - Type Unspecified