Basic Information
| Provider Information | |||||||||
| NPI: | 1003207648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULIKKOTIL | ||||||||
| FirstName: | SANITHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POOTHAKARY | ||||||||
| OtherFirstName: | SANITHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2845 TALL OAKS CT | ||||||||
| Address2: | APT. 23 | ||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483264165 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 N GROESBECK HWY | ||||||||
| Address2: | UNIT 175-F | ||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480431562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866270024 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401014646 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.