Provider Demographics
NPI:1104318096
Name:RAJENDRAN, SUMITHRA
Entity type:Individual
Prefix:MRS
First Name:SUMITHRA
Middle Name:
Last Name:RAJENDRAN
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 1:223 LITCHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3705
Mailing Address - Country:US
Mailing Address - Phone:224-795-2577
Mailing Address - Fax:
Practice Address - Street 1:9651 PRAIRIE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1948
Practice Address - Country:US
Practice Address - Phone:262-333-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14136-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist