Basic Information
| Provider Information | |||||||||
| NPI: | 1720284433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUPRAI | ||||||||
| FirstName: | SUKHDEEP | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.H.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR STE 116 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945888536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | 9255200010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2608 CENTRAL AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945873148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106750600 | ||||||||
| FaxNumber: | 5106750185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 01AX | 05 | CA | MEDICAID |