Provider Demographics
NPI:1639256886
Name:KOTJAHASAN, YUDELKA (PSYD)
Entity Type:Individual
Prefix:MS
First Name:YUDELKA
Middle Name:
Last Name:KOTJAHASAN
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 1:223 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1735
Mailing Address - Country:US
Mailing Address - Phone:413-846-4300
Mailing Address - Fax:413-732-0429
Practice Address - Street 1:33 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1301
Practice Address - Country:US
Practice Address - Phone:413-846-4300
Practice Address - Fax:413-732-0429
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANONE103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical