Healthcare Provider Details

I. General information

NPI: 1275190514
Provider Name (Legal Business Name): ANISA SUGANTAL SUPARMANIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WASHINGTON AVE
SCRANTON PA
18503-1828
US

IV. Provider business mailing address

2500 BISCAYNE BLVD APT 606
MIAMI FL
33137-4565
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-2383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMT217917
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA187217
License Number StateCA

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: