Enrollment Application Information:      Provider/Supplier Name: PANDEESWARI RAVEENDRAN       Provider/Supplier Specialty Type: PSYCHIATRY       State: MA      Form Type: AUTHORIZATION STATEMENT FOR ORGANIZATIONS (855R)      NPI: 1124247267      Web Tracking ID: T090920200003663      Signatory Name: FURQUAN SYED      Signatory Role: AUTHORIZED OFFICIAL      Topic/s Changed: Reassignment, Contact Person