Provider Demographics
NPI:1194063669
Name:KOLAVENNU, VIJAY R (PH D)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:R
Last Name:KOLAVENNU
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1514
Mailing Address - Country:US
Mailing Address - Phone:510-574-2032
Mailing Address - Fax:510-574-2054
Practice Address - Street 1:3300 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1514
Practice Address - Country:US
Practice Address - Phone:510-574-2032
Practice Address - Fax:510-574-2054
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health