Healthcare Provider Details

I. General information

NPI: 1780082651
Provider Name (Legal Business Name): MINOLI HORDAGODA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 S WINCHESTER BLVD STE 106
CAMPBELL CA
95008-1000
US

IV. Provider business mailing address

1215 PERMATA CT
SAN JOSE CA
95116-1086
US

V. Phone/Fax

Practice location:
  • Phone: 408-596-9067
  • Fax:
Mailing address:
  • Phone: 408-593-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW95765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: