Provider Demographics
NPI:1497363501
Name:SRIVASTAVA, POORTI
Entity Type:Individual
Prefix:
First Name:POORTI
Middle Name:
Last Name:SRIVASTAVA
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 1:25 N 14TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-6217
Mailing Address - Country:US
Mailing Address - Phone:408-569-9550
Mailing Address - Fax:
Practice Address - Street 1:25 N 14TH ST STE 400
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6217
Practice Address - Country:US
Practice Address - Phone:408-569-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health