Provider Demographics
NPI:1043378102
Name:KIRTIKAR, SUSHAMA U (MA)
Entity type:Individual
Prefix:MS
First Name:SUSHAMA
Middle Name:U
Last Name:KIRTIKAR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 CLOVERLAWN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1188
Mailing Address - Country:US
Mailing Address - Phone:813-960-2470
Mailing Address - Fax:813-264-7114
Practice Address - Street 1:16120 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6129
Practice Address - Country:US
Practice Address - Phone:813-264-7114
Practice Address - Fax:813-961-1388
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health