Provider Demographics
NPI:1952814436
Name:GOTTTAM, SRAVANTHI (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:SRAVANTHI
Middle Name:
Last Name:GOTTTAM
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 N DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1059
Mailing Address - Country:US
Mailing Address - Phone:909-396-8900
Mailing Address - Fax:909-396-9900
Practice Address - Street 1:706 N DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1059
Practice Address - Country:US
Practice Address - Phone:909-396-8900
Practice Address - Fax:909-396-9900
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23752235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist