Provider Demographics
NPI:1770202699
Name:POTTURI, SIVAMANOJNA VANI
Entity type:Individual
Prefix:
First Name:SIVAMANOJNA
Middle Name:VANI
Last Name:POTTURI
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 1:1918 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704
Mailing Address - Country:US
Mailing Address - Phone:510-548-9716
Mailing Address - Fax:
Practice Address - Street 1:1918 UNIVERSITY AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:510-548-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician