Provider Demographics
NPI:1629443346
Name:MAHADAVAN, KANAKAMALAR
Entity Type:Individual
Prefix:
First Name:KANAKAMALAR
Middle Name:
Last Name:MAHADAVAN
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 1:20 CHURCH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-1901
Mailing Address - Country:US
Mailing Address - Phone:914-421-0400
Mailing Address - Fax:914-421-0401
Practice Address - Street 1:20 CHURCH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1901
Practice Address - Country:US
Practice Address - Phone:914-421-0400
Practice Address - Fax:914-421-0401
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23211101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)