Provider Demographics
NPI:1811907801
Name:SRINIVASAN, PRATIBHA (MS CCC-A, CERT AVT)
Entity type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:MS CCC-A, CERT AVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4181
Mailing Address - Country:US
Mailing Address - Phone:804-290-0475
Mailing Address - Fax:804-290-0476
Practice Address - Street 1:1495 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5727
Practice Address - Country:US
Practice Address - Phone:571-633-0770
Practice Address - Fax:571-633-9666
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000379231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA69161OtherPROVIDER ID/OPTIMA HEALTH
VA140801OtherPROVIDER ID - ANTHEM
VA208069OtherPROVIDER ID - ANTHEM