Basic Information
| Provider Information | |||||||||
| NPI: | 1205837754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHALLA | ||||||||
| FirstName: | SHALINI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 57 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783542700 | ||||||||
| FaxNumber: | 9787404902 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783542700 | ||||||||
| FaxNumber: | 9787404902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 8704 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200514390 | 05 | IN | MEDICAID | 600018-048 | 01 | IN | MAGELLAN | OTHER | 200542200 | 05 | IN | MEDICAID | 000000358319 | 01 | IN | ANTHEM BCBS | OTHER |