Healthcare Provider Details

I. General information

NPI: 1639834096
Provider Name (Legal Business Name): SIRISHA R SUKRUTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WARREN ST
EUGENE OR
97405-1116
US

IV. Provider business mailing address

2300 WARREN ST
EUGENE OR
97405-1116
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-2828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17145
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: