Provider Demographics
NPI:1992014104
Name:VASUDEVAN, SANGEETHA
Entity Type:Individual
Prefix:
First Name:SANGEETHA
Middle Name:
Last Name:VASUDEVAN
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 1:1910 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3977
Mailing Address - Country:US
Mailing Address - Phone:707-781-7229
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35969225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist