Provider Demographics
NPI:1811508880
Name:LOKESHWARAN, MYTHILI REVATHI
Entity type:Individual
Prefix:
First Name:MYTHILI
Middle Name:REVATHI
Last Name:LOKESHWARAN
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 1:74 CUMBERLAND CT SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-5823
Mailing Address - Country:US
Mailing Address - Phone:910-600-2433
Mailing Address - Fax:
Practice Address - Street 1:2329 E WT HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213
Practice Address - Country:US
Practice Address - Phone:704-529-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NCA1106106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician