Provider Demographics
NPI:1649845736
Name:MUTHARAJU, PUTTA DIVYA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:PUTTA DIVYA
Middle Name:
Last Name:MUTHARAJU
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10278 BLACK MOUNTAIN RD APT 171
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3833
Mailing Address - Country:US
Mailing Address - Phone:408-601-8493
Mailing Address - Fax:
Practice Address - Street 1:5870 EL CAMINO REAL STE 101
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-8816
Practice Address - Country:US
Practice Address - Phone:760-539-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist