Provider Demographics
NPI:1447081476
Name:SURENDRAN, RAEYSHA (MS, ATC)
Entity type:Individual
Prefix:
First Name:RAEYSHA
Middle Name:
Last Name:SURENDRAN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2784
Mailing Address - Country:US
Mailing Address - Phone:937-312-7909
Mailing Address - Fax:
Practice Address - Street 1:6 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4079
Practice Address - Country:US
Practice Address - Phone:631-689-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0047922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer