Provider Demographics
NPI:1730701236
Name:BRAHMBHATT, DHARA
Entity type:Individual
Prefix:
First Name:DHARA
Middle Name:
Last Name:BRAHMBHATT
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 1:225 CEDAR HILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5900
Mailing Address - Country:US
Mailing Address - Phone:847-262-1401
Mailing Address - Fax:
Practice Address - Street 1:7360 N LINCOLN AVE STE 110
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1705
Practice Address - Country:US
Practice Address - Phone:855-855-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILJ20017485704OtherDRIVER'S LICENSE