Provider Demographics
NPI:1083962336
Name:GHASEMI, RAHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RAHA
Middle Name:
Last Name:GHASEMI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SMITH RANCH RD.
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-668-5955
Mailing Address - Fax:
Practice Address - Street 1:111 SMITH RANCH RD.
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-668-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY30857103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program