Provider Demographics
NPI:1083371918
Name:KUDAISYA, MEDHA S
Entity Type:Individual
Prefix:
First Name:MEDHA
Middle Name:S
Last Name:KUDAISYA
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 1:1450 WASHINGTON ST APT 416
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-9407
Mailing Address - Country:US
Mailing Address - Phone:347-558-5881
Mailing Address - Fax:
Practice Address - Street 1:368 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2112
Practice Address - Country:US
Practice Address - Phone:347-558-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06706800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health