Provider Demographics
NPI:1386413870
Name:GANDLA, SRUJANA
Entity type:Individual
Prefix:
First Name:SRUJANA
Middle Name:
Last Name:GANDLA
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 1:1320 NORTHVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2942
Mailing Address - Country:US
Mailing Address - Phone:586-785-0883
Mailing Address - Fax:
Practice Address - Street 1:7310 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3165
Practice Address - Country:US
Practice Address - Phone:313-896-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851117513104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker