Provider Demographics
NPI:1184812513
Name:DATTA, MALA (PH,D)
Entity type:Individual
Prefix:DR
First Name:MALA
Middle Name:
Last Name:DATTA
Suffix:
Gender:F
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 MASSACHUSETTS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:HAWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07641-1808
Mailing Address - Country:US
Mailing Address - Phone:201-952-9905
Mailing Address - Fax:
Practice Address - Street 1:294-298 STATE ST STE 1
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5544
Practice Address - Country:US
Practice Address - Phone:201-952-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100543600103T00000X
NY012711103T00000X
NY01271101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01271101OtherNYS LICENSE