Provider Demographics
NPI:1093005332
Name:BALAGURU, BALASOUNDHARI (PHD)
Entity Type:Individual
Prefix:
First Name:BALASOUNDHARI
Middle Name:
Last Name:BALAGURU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SOUNDHARI
Other - Middle Name:
Other - Last Name:BALAGURU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE 120BK LL23
Mailing Address - Street 2:CHILDREN'S HOSPITAL BOSTON DEPT OF PSYCHIATRY CHNP
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-919-3212
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL BOSTON DEPT OF PSYCHIATRY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-919-3212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8847103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent