Provider Demographics
NPI:1497373914
Name:KONSTAM, VARDA
Entity Type:Individual
Prefix:
First Name:VARDA
Middle Name:
Last Name:KONSTAM
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 1:2 AVERY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1002
Mailing Address - Country:US
Mailing Address - Phone:508-259-5802
Mailing Address - Fax:
Practice Address - Street 1:2 AVERY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1002
Practice Address - Country:US
Practice Address - Phone:508-259-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1902-PY-PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist