Provider Demographics
NPI:1396993168
Name:SURYAVANSHI, KAVITA (OT)
Entity type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:SURYAVANSHI
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W NEPESSING ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2150
Mailing Address - Country:US
Mailing Address - Phone:810-245-1900
Mailing Address - Fax:810-245-9080
Practice Address - Street 1:404 W NEPESSING ST
Practice Address - Street 2:SUITE B
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2150
Practice Address - Country:US
Practice Address - Phone:810-245-1900
Practice Address - Fax:810-245-9080
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002431225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5201002431OtherBCBS
OP21740Medicare PIN