Provider Demographics
NPI:1306068481
Name:MADABHUSHI, SOUMYA (PHD)
Entity type:Individual
Prefix:DR
First Name:SOUMYA
Middle Name:
Last Name:MADABHUSHI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 FAIRMOUNT AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2955
Mailing Address - Country:US
Mailing Address - Phone:732-877-7928
Mailing Address - Fax:
Practice Address - Street 1:1424 FAIRMOUNT AVE APT 309
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2955
Practice Address - Country:US
Practice Address - Phone:732-877-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017562103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling