Provider Demographics
NPI:1841855517
Name:MAHADEVAN, KALA
Entity type:Individual
Prefix:MRS
First Name:KALA
Middle Name:
Last Name:MAHADEVAN
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 1:2645 AZALEA BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-3208
Mailing Address - Country:US
Mailing Address - Phone:770-403-9676
Mailing Address - Fax:
Practice Address - Street 1:750 HAMMOND DR STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5532
Practice Address - Country:US
Practice Address - Phone:770-403-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-86172106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician