Provider Demographics
NPI:1194270173
Name:WARDAK, MINA
Entity type:Individual
Prefix:MISS
First Name:MINA
Middle Name:
Last Name:WARDAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39665 CATAMARAN CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1820
Mailing Address - Country:US
Mailing Address - Phone:510-789-6224
Mailing Address - Fax:
Practice Address - Street 1:424 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-286-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst