Provider Demographics
NPI:1780219089
Name:IYER, MALLIKA TARA
Entity type:Individual
Prefix:
First Name:MALLIKA
Middle Name:TARA
Last Name:IYER
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 1:7 BALMORRA RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1537
Mailing Address - Country:US
Mailing Address - Phone:603-553-5580
Mailing Address - Fax:
Practice Address - Street 1:64 S BEDFORD STREET
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803
Practice Address - Country:US
Practice Address - Phone:857-214-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHNHN16218503OtherNEW HAMPSHIRE