Basic Information
| Provider Information | |||||||||
| NPI: | 1316361967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NANDAMUDI | ||||||||
| FirstName: | DEEPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
| FaxNumber: | 8103851540 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
| FaxNumber: | 8103851540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2014 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
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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 | 1041C0700X | 6801068852 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.