Provider Demographics
NPI:1801260633
Name:KONDURU, LAKSHMI SUPRAJA
Entity type:Individual
Prefix:
First Name:LAKSHMI SUPRAJA
Middle Name:
Last Name:KONDURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 RUSSELL DR APT C37
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 POST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-2257
Practice Address - Country:US
Practice Address - Phone:516-333-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist