Provider Demographics
NPI:1629609573
Name:RAMDHANY CORREA, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:RAMDHANY CORREA
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 1:205 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1406
Mailing Address - Country:US
Mailing Address - Phone:781-761-5089
Mailing Address - Fax:
Practice Address - Street 1:549 PINE ST APT 19
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-2336
Practice Address - Country:US
Practice Address - Phone:347-356-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-19-39759103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000023532OtherBMC
MA99618201OtherNETWORK HEALTH
MA1004745OtherNHP
MA042611055OtherTAX ID
MA1004745OtherFALLON
MA1303287OtherMBHP
MAM18633OtherBCBS