Provider Demographics
NPI:1164933552
Name:SHENBAGAM, SHRUTI (MS, LCGC)
Entity Type:Individual
Prefix:MISS
First Name:SHRUTI
Middle Name:
Last Name:SHENBAGAM
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5976
Mailing Address - Fax:559-353-6711
Practice Address - Street 1:9300 VALLEY CHILDRENS PLACE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636
Practice Address - Country:US
Practice Address - Phone:559-353-5976
Practice Address - Fax:559-353-6711
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000876101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional