Healthcare Provider Details

I. General information

NPI: 1033676556
Provider Name (Legal Business Name): NIJETHA BASKAR BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 RIVER OAKS PKWY
SAN JOSE CA
95134-1907
US

IV. Provider business mailing address

9752 CREBS AVE
NORTHRIDGE CA
91324-1912
US

V. Phone/Fax

Practice location:
  • Phone: 760-710-2836
  • Fax:
Mailing address:
  • Phone: 818-439-7613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberF2995671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: