Provider Demographics
NPI:1326453424
Name:VADGAMA, YAGNESH
Entity Type:Individual
Prefix:
First Name:YAGNESH
Middle Name:
Last Name:VADGAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17609 VENTURA BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5126
Mailing Address - Country:US
Mailing Address - Phone:818-501-8352
Mailing Address - Fax:
Practice Address - Street 1:17609 VENTURA BLVD STE 215
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5126
Practice Address - Country:US
Practice Address - Phone:818-501-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-16792103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA272115023OtherPRIVATE COMPANY