Provider Demographics
NPI:1033763172
Name:SELVARAJ, AMBICA
Entity Type:Individual
Prefix:
First Name:AMBICA
Middle Name:
Last Name:SELVARAJ
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 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:101 JOSE FIGUERES AVENUE
Practice Address - Street 2:STE 50
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-2022
Practice Address - Country:US
Practice Address - Phone:408-207-0560
Practice Address - Fax:408-642-6052
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10271736OtherKAISER