Provider Demographics
NPI:1073995452
Name:MANSOURI, FARIBA (PHD)
Entity Type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S LAKE AVE # 842
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3515
Mailing Address - Country:US
Mailing Address - Phone:626-765-5606
Mailing Address - Fax:
Practice Address - Street 1:446 S MARENGO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3113
Practice Address - Country:US
Practice Address - Phone:626-765-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27134103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical