Provider Demographics
NPI:1902036551
Name:PRASAD, SHITAL R (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:SHITAL
Middle Name:R
Last Name:PRASAD
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RACHEL DR
Mailing Address - Street 2:APT 3
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8623
Mailing Address - Country:US
Mailing Address - Phone:731-660-3471
Mailing Address - Fax:731-660-3471
Practice Address - Street 1:121 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6011
Practice Address - Country:US
Practice Address - Phone:731-664-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000002866235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist