Provider Demographics
NPI:1740534825
Name:NAGALLA, KALYAN (SPEECH THERAPIST)
Entity type:Individual
Prefix:MR
First Name:KALYAN
Middle Name:
Last Name:NAGALLA
Suffix:
Gender:M
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 S 154TH ST
Mailing Address - Street 2:APT: A108
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2145
Mailing Address - Country:US
Mailing Address - Phone:206-257-9251
Mailing Address - Fax:
Practice Address - Street 1:516 176TH ST E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8335
Practice Address - Country:US
Practice Address - Phone:253-683-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA426607HOtherWASHINGTON STATE EDUCATION CERTIFICATE INITIAL ESA
WALL60265399OtherWASHINGTON STATE DEPARTMENT OF HEALTH