Healthcare Provider Details

I. General information

NPI: 1063327831
Provider Name (Legal Business Name): SHAILEE VAKULABHARANAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MAIN ST APT 310
WATERTOWN MA
02472-4344
US

IV. Provider business mailing address

275 MAIN ST APT 310
WATERTOWN MA
02472-4344
US

V. Phone/Fax

Practice location:
  • Phone: 314-679-0309
  • Fax:
Mailing address:
  • Phone: 314-679-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHAILEE VAKULABHARANAM
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: M.ED
Phone: 314-679-0309