Provider Demographics
NPI:1588875629
Name:SURYAVANSHI, DEEPALI (OTRL)
Entity type:Individual
Prefix:MS
First Name:DEEPALI
Middle Name:
Last Name:SURYAVANSHI
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 EVERGREEN CV
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-1894
Mailing Address - Country:US
Mailing Address - Phone:870-735-2129
Mailing Address - Fax:
Practice Address - Street 1:200 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:879-735-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1965225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist