Healthcare Provider Details

I. General information

NPI: 1104143197
Provider Name (Legal Business Name): POONAM NINA BANERJEE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20409 YORBA LINDA BLVD STE 129-K
YORBA LINDA CA
92886-3042
US

IV. Provider business mailing address

20409 YORBA LINDA BLVD STE 129-K
YORBA LINDA CA
92886-3042
US

V. Phone/Fax

Practice location:
  • Phone: 917-370-6350
  • Fax: 949-208-6981
Mailing address:
  • Phone: 917-370-6350
  • Fax: 949-208-6981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY24249
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 24249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: