1356048466 NPI number — DR. MAVATH SAILAJA SUBRAMANIAM LMFT

Table of content: DR. MAVATH SAILAJA SUBRAMANIAM LMFT (NPI 1356048466)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356048466 NPI number — DR. MAVATH SAILAJA SUBRAMANIAM LMFT

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
SUBRAMANIAM

Provider First Name:
MAVATH SAILAJA

Provider Middle Name:

Provider Name Prefix Text:
DR.

Provider Name Suffix Text:

Provider Credential Text:
LMFT

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
SUBRAMANIAM

Provider Other First Name:
SAILA

Provider Other Middle Name:

Provider Other Name Prefix Text:
DR.

Provider Other Name Suffix Text:

Provider Other Credential Text:
LMFT

Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356048466

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
02/09/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1669 WOLF CREEK DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
CANTON

Provider Business Mailing Address State Name:
MI

Provider Business Mailing Address Postal Code:
48187-7712

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
517-927-6609

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 JALAN LIMAU PURUT

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
KUALA LUMPUR

Provider Business Practice Location Address State Name:
FEDERAL TERRITORY

Provider Business Practice Location Address Postal Code:
59000

Provider Business Practice Location Address Country Code:
MY

Provider Business Practice Location Address Telephone Number:
12-936-6091

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
02/09/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 106H00000X , with the licence number: 4101006863 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .