Provider Demographics
NPI:1336801307
Name:SRINIVASAN, MULLAI (BCBA)
Entity Type:Individual
Prefix:
First Name:MULLAI
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1091
Mailing Address - Country:US
Mailing Address - Phone:860-430-1340
Mailing Address - Fax:860-812-2399
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1091
Practice Address - Country:US
Practice Address - Phone:860-430-1340
Practice Address - Fax:860-812-2399
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1301103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst