Provider Demographics
NPI:1457879512
Name:RAMACHANDRA, DIVYA BAKTHA (MS)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:BAKTHA
Last Name:RAMACHANDRA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 207
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2658
Practice Address - Country:US
Practice Address - Phone:708-684-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL247.000099170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS