Provider Demographics
NPI:1679312722
Name:MALLIGERE BASAVARAJU, VENUGOPAL (SLP)
Entity type:Individual
Prefix:
First Name:VENUGOPAL
Middle Name:
Last Name:MALLIGERE BASAVARAJU
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 TAMPA AVE UNIT 183
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1404
Mailing Address - Country:US
Mailing Address - Phone:818-730-6870
Mailing Address - Fax:
Practice Address - Street 1:10801 LINDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4441
Practice Address - Country:US
Practice Address - Phone:818-275-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist