Provider Demographics
NPI:1275646036
Name:DATTA, PURNA CHANDRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PURNA
Middle Name:CHANDRA
Last Name:DATTA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 SHORELINE DR
Mailing Address - Street 2:SUITE A-6
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-5495
Mailing Address - Country:US
Mailing Address - Phone:209-406-6817
Mailing Address - Fax:209-477-2935
Practice Address - Street 1:7510 SHORELINE DR
Practice Address - Street 2:SUITE A-6
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-5495
Practice Address - Country:US
Practice Address - Phone:209-406-6817
Practice Address - Fax:209-477-2935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY10808OtherBOARD OF PSYCHOLOGY
CAOPL108080Medicare PIN