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General NPI Number Information
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NPI Number | 1447081476
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Entity Type | Individual
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Provider Name | RAEYSHA SURENDRAN MS, ATC
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Gender | Female
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Dates
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Enumeration Date | 08/12/2024
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Last Update Date | 09/15/2024
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Provider Practice Location Address
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Address Line | 6 TECHNOLOGY DR
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City | EAST SETAUKET
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State | NY
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Zip | 11733-4079
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Country | US
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Telephone | 631-689-4197
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Fax |
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Provider Business Mailing Address
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Address Line | 366 BROADWAY
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City | AMITYVILLE
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State | NY
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Zip | 11701-2784
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Country | US
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Telephone | 937-312-7909
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 004792
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License Number State | NY
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