Provider Demographics
NPI:1891184339
Name:SUBRAMANI, MUKUNTHAN
Entity type:Individual
Prefix:MR
First Name:MUKUNTHAN
Middle Name:
Last Name:SUBRAMANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7156
Mailing Address - Country:US
Mailing Address - Phone:323-423-7187
Mailing Address - Fax:
Practice Address - Street 1:1664 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-7156
Practice Address - Country:US
Practice Address - Phone:323-423-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist