Provider Demographics
NPI:1790269074
Name:ISHWARGOND, ROOPA BALAPPA
Entity Type:Individual
Prefix:MRS
First Name:ROOPA
Middle Name:BALAPPA
Last Name:ISHWARGOND
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 1:1055 E COLORADO BLVD STE 560
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2380
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:
Practice Address - Street 1:1479 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4934
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician