Provider Demographics
NPI:1871317750
Name:PRAKASH, KRUPANIDHI
Entity type:Individual
Prefix:
First Name:KRUPANIDHI
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CAMINO SIERRA VISTA
Mailing Address - Street 2:OSW
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-467-2504
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VISTA
Practice Address - Street 2:OSW
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-467-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSAH-2024-0112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist