Healthcare Provider Details

I. General information

NPI: 1104778844
Provider Name (Legal Business Name): SVETLANA MARY BHALLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2026
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 MASS AVE
BOSTON MA
02118-2620
US

IV. Provider business mailing address

960 MASS AVE
BOSTON MA
02118-2620
US

V. Phone/Fax

Practice location:
  • Phone: 857-270-4385
  • Fax:
Mailing address:
  • Phone: 716-622-7478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW230120
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: