Provider Demographics
NPI:1558449660
Name:VAYALAKKARA, JYOTHI (PSYD)
Entity Type:Individual
Prefix:
First Name:JYOTHI
Middle Name:
Last Name:VAYALAKKARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 DEMING ST
Mailing Address - Street 2:PROVIDERCARE PLUS, PC
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3740
Mailing Address - Country:US
Mailing Address - Phone:860-644-4472
Mailing Address - Fax:860-644-3001
Practice Address - Street 1:152 DEMING ST
Practice Address - Street 2:PROVIDERCARE PLUS, PC
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3740
Practice Address - Country:US
Practice Address - Phone:860-644-4472
Practice Address - Fax:860-644-3001
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002590103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002590CT01OtherANTHEM BCBS