Provider Demographics
NPI:1285313759
Name:IHALAWITHANAGE, NISHANTHI
Entity type:Individual
Prefix:
First Name:NISHANTHI
Middle Name:
Last Name:IHALAWITHANAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 TURNPIKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1755
Mailing Address - Country:US
Mailing Address - Phone:860-208-6491
Mailing Address - Fax:
Practice Address - Street 1:333 TURNPIKE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1755
Practice Address - Country:US
Practice Address - Phone:860-208-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician