Healthcare Provider Details

I. General information

NPI: 1285229666
Provider Name (Legal Business Name): KOODRUT PANESAR B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SAN PABLO AVE
OAKLAND CA
94612-1121
US

IV. Provider business mailing address

2545 SAN PABLO AVE
OAKLAND CA
94612-1121
US

V. Phone/Fax

Practice location:
  • Phone: 510-446-7150
  • Fax:
Mailing address:
  • Phone: 510-446-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC22829
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: