Healthcare Provider Details

I. General information

NPI: 1083371918
Provider Name (Legal Business Name): MEDHA S KUDAISYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2021
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

368 MAIN ST
CHATHAM NJ
07928-2112
US

IV. Provider business mailing address

1450 WASHINGTON ST APT 416
HOBOKEN NJ
07030-9407
US

V. Phone/Fax

Practice location:
  • Phone: 347-558-5881
  • Fax:
Mailing address:
  • Phone: 347-558-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SC06354500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: