Provider Demographics
NPI:1659963676
Name:BERGANCIANO, SHELBY ELIZABETH
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:ELIZABETH
Last Name:BERGANCIANO
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 1:1919 FRUITDALE AVE APT J604
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4928
Mailing Address - Country:US
Mailing Address - Phone:209-331-6206
Mailing Address - Fax:
Practice Address - Street 1:1171 HOMESTEAD RD STE 250
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5485
Practice Address - Country:US
Practice Address - Phone:408-320-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11798071OtherKISER PERMANENTE