Provider Demographics
NPI:1972017549
Name:PSYCHOPHYLAXIS INSTITUTE LLC
Entity Type:Organization
Organization Name:PSYCHOPHYLAXIS INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MUDALODU
Authorized Official - Middle Name:
Authorized Official - Last Name:VASUDEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-688-3579
Mailing Address - Street 1:164 W INVITAR LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-2036
Mailing Address - Country:US
Mailing Address - Phone:646-688-3579
Mailing Address - Fax:
Practice Address - Street 1:2470 E FLAMINGO RD STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5200
Practice Address - Country:US
Practice Address - Phone:702-544-3849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17489207Q00000X
MI4301102270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty