Provider Demographics
NPI:1831208560
Name:SREENIVASAN, SHOBA KOMALA (PHD)
Entity type:Individual
Prefix:DR
First Name:SHOBA
Middle Name:KOMALA
Last Name:SREENIVASAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:11301 WILSHIRE BOULEVARD
Mailing Address - Street 2:691-B 116, BUILDING 258 ROOM 222
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:691-B 116, BUILDING 258 ROOM 222
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical