Provider Demographics
NPI:1629393194
Name:KALLARAKAL, KEZIAH (PSYD)
Entity Type:Individual
Prefix:
First Name:KEZIAH
Middle Name:
Last Name:KALLARAKAL
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 1:3811 BROADWAY FL 3
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4045
Mailing Address - Country:US
Mailing Address - Phone:718-726-5953
Mailing Address - Fax:718-204-5308
Practice Address - Street 1:3811 BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4045
Practice Address - Country:US
Practice Address - Phone:718-726-5953
Practice Address - Fax:718-204-5308
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 017125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist