Provider Demographics
NPI:1588435739
Name:KAMARAJ, MATHIVANAN
Entity type:Individual
Prefix:DR
First Name:MATHIVANAN
Middle Name:
Last Name:KAMARAJ
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 1:3500 DATA DR APT 350
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7954
Mailing Address - Country:US
Mailing Address - Phone:510-455-6188
Mailing Address - Fax:
Practice Address - Street 1:2865 SUNRISE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-6108
Practice Address - Country:US
Practice Address - Phone:805-778-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician