Healthcare Provider Details

I. General information

NPI: 1386323731
Provider Name (Legal Business Name): SHREYA GANNARAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 OXFORD RD STE D7
MILFORD CT
06460-3851
US

IV. Provider business mailing address

417 POPLAR ST APT 3
NEW HAVEN CT
06513-3191
US

V. Phone/Fax

Practice location:
  • Phone: 475-414-8084
  • Fax:
Mailing address:
  • Phone: 804-298-0944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: