Provider Demographics
NPI:1457505547
Name:BASAVARAJU, KAVITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:
Last Name:BASAVARAJU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 ELM DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3013
Mailing Address - Country:US
Mailing Address - Phone:516-376-5150
Mailing Address - Fax:
Practice Address - Street 1:90 GLEN COVE RD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1038
Practice Address - Country:US
Practice Address - Phone:516-376-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009982103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical