Healthcare Provider Details

I. General information

NPI: 1144157025
Provider Name (Legal Business Name): MITAL YATISHCHANDRA SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 HOLLY HILL DR
SAN JOSE CA
95122-3719
US

IV. Provider business mailing address

1071 HOLLY HILL DR
SAN JOSE CA
95122-3719
US

V. Phone/Fax

Practice location:
  • Phone: 510-706-4498
  • Fax:
Mailing address:
  • Phone: 510-706-4498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-17499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: