Provider Demographics
NPI:1083974430
Name:MAHMOODI, VINUS (PHD)
Entity Type:Individual
Prefix:DR
First Name:VINUS
Middle Name:
Last Name:MAHMOODI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:VENUS
Other - Middle Name:
Other - Last Name:MAHMOODI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1295 5TH AVE APT 11C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3130
Mailing Address - Country:US
Mailing Address - Phone:510-557-5301
Mailing Address - Fax:
Practice Address - Street 1:710 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3726
Practice Address - Country:US
Practice Address - Phone:510-557-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2021-07-19
Deactivation Date:2018-10-01
Deactivation Code:
Reactivation Date:2018-10-10
Provider Licenses
StateLicense IDTaxonomies
NY022918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical