Provider Demographics
NPI:1174027429
Name:KANDASAMI, PRAVEENA
Entity Type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:KANDASAMI
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 1:801 ALBANY ST
Mailing Address - Street 2:FL G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:DEPARTMENT OF OUTPATIENT PSYCHIATRY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-0211
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1243811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical