Provider Demographics
NPI:1689377665
Name:ABEKOONGEDARA, SAMANI SHYAMINDU
Entity Type:Individual
Prefix:
First Name:SAMANI
Middle Name:SHYAMINDU
Last Name:ABEKOONGEDARA
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 1:2110 BROADLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-7324
Mailing Address - Country:US
Mailing Address - Phone:860-830-5396
Mailing Address - Fax:
Practice Address - Street 1:77 HARTLAND ST STE 108
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3259
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician