Provider Demographics
NPI:1942890934
Name:SHINDE, POOJA
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:SHINDE
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 1:2116 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1237
Mailing Address - Country:US
Mailing Address - Phone:213-493-4664
Mailing Address - Fax:
Practice Address - Street 1:2116 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1237
Practice Address - Country:US
Practice Address - Phone:213-493-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CASQV00761220324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility