Provider Demographics
NPI:1992367882
Name:GOWDA, SHANTHA (PSYD)
Entity Type:Individual
Prefix:
First Name:SHANTHA
Middle Name:
Last Name:GOWDA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 LA SELVA ST APT 311
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2139
Mailing Address - Country:US
Mailing Address - Phone:706-631-0824
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST FL 2
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-498-3931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist