Provider Demographics
NPI:1104130822
Name:BALAGURU, ARAVINTHAN
Entity type:Individual
Prefix:
First Name:ARAVINTHAN
Middle Name:
Last Name:BALAGURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39420 LIBERTY ST
Mailing Address - Street 2:STE 140
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2200
Mailing Address - Country:US
Mailing Address - Phone:510-745-9151
Mailing Address - Fax:510-745-9152
Practice Address - Street 1:39420 LIBERTY ST
Practice Address - Street 2:STE 140
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2200
Practice Address - Country:US
Practice Address - Phone:510-745-9151
Practice Address - Fax:510-745-9152
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY31336103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program