Healthcare Provider Details

I. General information

NPI: 1639870843
Provider Name (Legal Business Name): DEEPTHI KALLAKURI CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEEPTHI KALLAKURI CEP

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE STREET
ENGLEWOOD NJ
07631-0763
US

IV. Provider business mailing address

329 S PLEASANT AVE
RIDGEWOOD NJ
07450-5335
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3285
  • Fax:
Mailing address:
  • Phone: 919-454-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: