Provider Demographics
NPI:1710546791
Name:KODIYALAM, GAYATHRI
Entity Type:Individual
Prefix:
First Name:GAYATHRI
Middle Name:
Last Name:KODIYALAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:GAYA
Other - Middle Name:
Other - Last Name:KODIYALAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:150 E 34TH ST APT 505
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4772
Mailing Address - Country:US
Mailing Address - Phone:908-477-1703
Mailing Address - Fax:
Practice Address - Street 1:79 WALKER ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3981
Practice Address - Country:US
Practice Address - Phone:212-337-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103035104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker