Provider Demographics
NPI:1386753358
Name:MUTYALA, ANUPA (AUD CCC-A)
Entity type:Individual
Prefix:
First Name:ANUPA
Middle Name:
Last Name:MUTYALA
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4678 177TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-6517
Mailing Address - Country:US
Mailing Address - Phone:206-987-5467
Mailing Address - Fax:206-987-3599
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:M/S W6665
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-5467
Practice Address - Fax:206-987-3599
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8437089Medicaid
WALD00004077OtherPROFESSIONAL LICENSE NUMB