Provider Demographics
NPI:1912691684
Name:SUBAWICKRAMA, SUGANDIKA THILOKESHWARY (DSL)
Entity Type:Individual
Prefix:DR
First Name:SUGANDIKA
Middle Name:THILOKESHWARY
Last Name:SUBAWICKRAMA
Suffix:
Gender:F
Credentials:DSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 MEADOWVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-3737
Mailing Address - Country:US
Mailing Address - Phone:347-322-9653
Mailing Address - Fax:
Practice Address - Street 1:6802 MEADOWVIEW AVE
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-3737
Practice Address - Country:US
Practice Address - Phone:347-322-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00538400101YP2500X
NY005448-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional