Provider Demographics
NPI:1851669667
Name:PENNSYLVANIA STATE UNIVERSITY
Entity Type:Organization
Organization Name:PENNSYLVANIA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NIMISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTTIAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-575-8034
Mailing Address - Street 1:1051 TEABERRY LN
Mailing Address - Street 2:D 206
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2986
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 FORD BLDG
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802-3003
Practice Address - Country:US
Practice Address - Phone:814-865-3584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010567253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care