MEDICARE: SHIRANI M PATHAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS28153	CA

General Provider Information

NPI Number	:	1326571647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIRANI M PATHAK

Provider Business Mailing Address
First Line	:	PO BOX 24813
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95154-4813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 ROSS AVE STE 308
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-3039
Country	:	US
Telephone Number	:	408-502-6790
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHIRANI M PATHAK
Credential	:	LCSW
Telephone Number	:	408-502-6790

Provider Enumeration Date	:	04/04/2017
Last Update Date	:	04/04/2017

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