Provider Demographics
NPI:1750759825
Name:ETHIRAJU, GIRIRAJ (MA SLP)
Entity type:Individual
Prefix:
First Name:GIRIRAJ
Middle Name:
Last Name:ETHIRAJU
Suffix:
Gender:M
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 NECTAR DR
Mailing Address - Street 2:APT 726
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-7117
Mailing Address - Country:US
Mailing Address - Phone:734-502-8808
Mailing Address - Fax:
Practice Address - Street 1:8230 NECTAR DRIVE
Practice Address - Street 2:APT 726
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187
Practice Address - Country:US
Practice Address - Phone:734-502-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000753235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist