Provider Demographics
NPI:1245095827
Name:SAMUDRALA, SRIMAYE
Entity type:Individual
Prefix:
First Name:SRIMAYE
Middle Name:
Last Name:SAMUDRALA
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 1:3045 GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-6703
Mailing Address - Country:US
Mailing Address - Phone:510-688-8166
Mailing Address - Fax:
Practice Address - Street 1:3045 GROVE WAY
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-6703
Practice Address - Country:US
Practice Address - Phone:510-688-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician