Provider Demographics
NPI:1386440774
Name:KOLLI, PALLAVI SRUTHI
Entity type:Individual
Prefix:
First Name:PALLAVI
Middle Name:SRUTHI
Last Name:KOLLI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54905
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-4905
Mailing Address - Country:US
Mailing Address - Phone:858-775-5206
Mailing Address - Fax:
Practice Address - Street 1:713 W COMMONWEALTH AVE STE C
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1612
Practice Address - Country:US
Practice Address - Phone:714-879-4274
Practice Address - Fax:714-879-2274
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician