Provider Demographics
NPI:1821765298
Name:HEGDE, MANJUSHREE M
Entity Type:Individual
Prefix:
First Name:MANJUSHREE
Middle Name:M
Last Name:HEGDE
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:600 ARABIAN COLT DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2354
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4202103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst