Provider Demographics
NPI:1831089812
Name:GANGATHARAM, SUDHAGAR (OTR/L)
Entity type:Individual
Prefix:
First Name:SUDHAGAR
Middle Name:
Last Name:GANGATHARAM
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5082
Mailing Address - Country:US
Mailing Address - Phone:604-551-2508
Mailing Address - Fax:
Practice Address - Street 1:100 E KANSAS ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-1616
Practice Address - Country:US
Practice Address - Phone:913-758-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-04467225X00000X, 225XG0600X, 225XL0004X, 225XP0019X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation