Basic Information
| Provider Information | |||||||||
| NPI: | 1447528369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAKRAVARTI | ||||||||
| FirstName: | PRAMA | ||||||||
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| Credential: | PHD, HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993528650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099422028 | ||||||||
| FaxNumber: | 5099423218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2011 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 20042688A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | PY60465923 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | PY60465923 | 05 | WA | MEDICAID |