Provider Demographics
NPI:1013939263
Name:SUNDRAM, SUBASHINI (OTR)
Entity Type:Individual
Prefix:
First Name:SUBASHINI
Middle Name:
Last Name:SUNDRAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22869 FEASTER BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-4229
Mailing Address - Country:US
Mailing Address - Phone:660-428-2321
Mailing Address - Fax:
Practice Address - Street 1:204 SEMINARY ST.
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-0338
Practice Address - Country:US
Practice Address - Phone:660-438-6993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004255225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266598Medicare ID - Type Unspecified