Provider Demographics
NPI:1740973130
Name:KERUR, SHAMBHAVI
Entity type:Individual
Prefix:
First Name:SHAMBHAVI
Middle Name:
Last Name:KERUR
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 1:160 E. VIRGINIA ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5817
Mailing Address - Country:US
Mailing Address - Phone:408-938-2113
Mailing Address - Fax:408-579-6143
Practice Address - Street 1:160 E. VIRGINIA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5817
Practice Address - Country:US
Practice Address - Phone:408-938-2113
Practice Address - Fax:408-579-6143
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1541000124101YA0400X
171M00000X, 390200000X
CAAPCC16951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program