Healthcare Provider Details

I. General information

NPI: 1821765298
Provider Name (Legal Business Name): MANJUSHREE M HEGDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 S MASON RD STE 10
KATY TX
77450-7729
US

IV. Provider business mailing address

PO BOX 33568
SAN DIEGO CA
92163-3568
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number4202
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: