Provider Demographics
NPI:1023638582
Name:PRAKASH, SUPRAJA (MS, CGC)
Entity type:Individual
Prefix:
First Name:SUPRAJA
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E CAMPBELL AVE APT 4032
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4275
Mailing Address - Country:US
Mailing Address - Phone:913-553-8720
Mailing Address - Fax:
Practice Address - Street 1:1920 E CAMBRIDGE AVE.
Practice Address - Street 2:ROSENBERG BLDG., SUITE 304
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-933-5503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS