Provider Demographics
NPI:1306969936
Name:GANESAN, SHANTHI PATNAIK (LICSW)
Entity type:Individual
Prefix:MS
First Name:SHANTHI
Middle Name:PATNAIK
Last Name:GANESAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:SHANTHI
Other - Middle Name:GANESAN
Other - Last Name:PATNAIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:33 BEDFORD ST STE 12
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4403
Mailing Address - Country:US
Mailing Address - Phone:617-763-4940
Mailing Address - Fax:
Practice Address - Street 1:33 BEDFORD ST STE 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4403
Practice Address - Country:US
Practice Address - Phone:617-763-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1118371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical