Healthcare Provider Details

I. General information

NPI: 1467878983
Provider Name (Legal Business Name): MS. SRILAYA KUDARAVALLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

IV. Provider business mailing address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

V. Phone/Fax

Practice location:
  • Phone: 630-405-8768
  • Fax:
Mailing address:
  • Phone: 630-405-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: