Provider Demographics
NPI:1770070179
Name:SHUKLA, POONAM MINNIE (LMFT)
Entity type:Individual
Prefix:MRS
First Name:POONAM
Middle Name:MINNIE
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19450 BURGUNDY WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-6130
Mailing Address - Country:US
Mailing Address - Phone:408-406-5525
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-259-2273
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100198171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator