Provider Demographics
NPI:1033829551
Name:TAVAFI, MARAL
Entity Type:Individual
Prefix:
First Name:MARAL
Middle Name:
Last Name:TAVAFI
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 1:6041 VARIEL AVE APT 551
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3865
Mailing Address - Country:US
Mailing Address - Phone:818-577-7546
Mailing Address - Fax:
Practice Address - Street 1:2102 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1001
Practice Address - Country:US
Practice Address - Phone:818-577-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health